Forms

Member Forms and Information

Appeals Rights & Requests

	Form Name
	Member Appeal Request Form
	Right to Appeal Notice

Group

	Form Name
	Coordination of Benefits Questionnaire
	Dependent Certification Form
	Designation of Personal Representative
	Disabled Dependent Request for Extension of Coverage
	HRA Claim Form
	Medical Claim Form
	Member Handbook
	Member Handbook - ES
	Preventive Care Benefits
	Preventive Care Benefits - ES
	Request for Personal Health Information
	Transplant Travel and Lodging Expense Form
	Where to Go For Care
	Where to Go For Care - ES

Flexible Spending Account

	Form Name
	FSA Claim Form
	FSA Election Form with Grace Period
	FSA Election Form with Rollover Provision
	FSA Eligible/Ineligible/OTC Expenses
	FSA Medical Necessity Form
	FSA Program Information
	FSA Secondary Card Request
	FSA — Step by Step
	FSA Substantiation Form
	FSA Worksheet

Group Term Life

	Form Name
	Designation of Beneficiary Form
	Group Life Insurance Claim Form

Educational Materials

	Form Name
	Antidepressant Medication
	Asthma Medication Ratio: Ages 19-64 (AMR)
	Managing Heart Failure
	My Heart Failure Management Guide
	Prevention of Diabetic Hospital Admissions

QCARE Health Management Programs

	Form Name
	Diabetes Assessment Form
	Hypertension Assessment Form
	Maternal Health Appraisal Form
	Maternity Notification Form

MediQ65

	Form Name
	MediQ65 Application for Coverage
	MediQ65 Dental Claim Form
	MediQ65 Payment Authorization Form
	Notice of Replacement Questionnaire