Forms and Documents Active Employee

Forms and Documents

Health, Flexible Benefits, and Life Insurance	To view, click on one of the documents listed below. Authorization for Use and Disclosure of Health Information Form Claim Form DAKOTACARE Direct Deposit Authorization Form DAKOTACARE Flex Orthodontia Claim Form Evidence of Insurability Form Family Status Change Form Health Savings Account Form Incapacitated Dependent Child Form Life/Beneficiary Electronic Enrollment Form Life Enrollment Form Short Term Disability Claim Form Student Verification Form Tobacco Use Election Form Waiver of Life Premium Form
Pharmacy	Express Scripts (ESI) Prescription Drug Claim Form ESI Formulary List Look Up ESI Pharmacy List FY 2012 Formulary FY 2012 Formulary Changes FAQ Maintenance Drug List
Other	Bundled Payment Procedures and Participating Facilities Contracted Facilities for MRI and CT Scans Confirmation Statement/Current Coverage FY 2012 and FY 2013 Health Plan Comparison Chart FY 2012 Decision Guide FY 2012 Fact Sheet Health Assessment Health Screening HIPAA Pre-authorization Listing RFP 25947 RFP 25986 RFP 26047 RFP 26050
Frequently Asked Questions (FAQS)	$300 Deductible/Copay Plan $1,000 Deductible Plan $2,000 Deductible Plan HSA Compatible Health Assessment Health Screening Healthy Employees Latitude Program Prescription Drug FAQ for $300 Deductible/Copay and $1,000 Deductible Plans Tobacco Free