Forms

General Forms
Medicare Creditable Coverage Model Disclosure Notice (DOC)
Medicare Non-Creditable Coverage Model Disclosure Notice (DOC)
Membership Change Report
Group Health Plan Designated Contact Form
Small Employer Certification Form
Broker Application for a Small Employer Benefits Policy

HIPAA Authorizations
HIPAA Member Authorization Form
DTL Member Authorization Form

Enrollment & Claim Forms
Employee Enrollment/Change Form

Personal Choice Forms
Student Verification Form (#7215)
MedigapSecurity Enrollment Form and Replacement Notice
Application to Continue Coverage for Handicapped Dependent Child (#01418)
Personal Choice Out-of-Network Claim Form
Future Scripts Prescription Mail Order Form
IBC Davis Vision Claim Form

Keystone HMO & POS Forms
KHPE Dependent Verification Form
Application to Continue Coverage for Handicapped Dependent Child (#01418)
Point of Service Claim Form (#03925)
Future Scripts Prescription Mail Order Form
IBC Davis Vision Claim Form

Health Savings Account Forms
Contact DTL for H S A forms

United Concordia Forms
UCCI Enrollment Form
UCCI Claim Form