Advance Care Planning
for health care proxies, living wills and more
Medical Claim Form
- Use to submit medical services from a provider, hospital, DME vendor, etc. Also use for vision services including eyewear (see exception below **). Do not use to submit prescription drug services. All prescription drug services should be submitted on the prescription drug claim form.
Dental Claim Form
Flexible Spending Account or Medical Reimbursement Account Forms
This link will take you to the Lifetime Benefit Solutions Website.
Prescription Drug Claim Form 2017
Use for prescriptions that were purchased on or after Jan. 1, 2017.
Prescription Drug Claim Form 2016
Use for prescriptions that were purchased during the year 2016.
Compound Prescription Drug Claim Form 2016
Use for prescriptions that were purchased during the year 2016. The Compound Prescription Drug Claim Form must also accompany the Prescription Drug Claim Form (enclosed) for all compound medications
Vision Claim Form
- **For members with Vision Care II policies only. All others, use medical claim form above.