Quick + easy!

Whether you’re an employer, plan member, or advisor, you can quickly + easily find the forms you need.

Employers

Employer Forms

Members

Member Forms

Advisors

Advisor Forms
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We partner with the best, so you get the best. Through our exclusive partners of underwriters, technology experts, and healthcare affiliates, we deliver premium personalized group health insurance and solutions

Employers

 

OAD Eligibility Form

To be completed when enrolling a new over-age-dependant or changing existing coverage information.
Download
 

TPA Enrollment Form

Used for Third Party Administration (TPA) when enrolling new employees or changing existing coverage information.
Download
 

Web Connectivity Requirements — Existing Client

This document lists minimum hardware and software requirements for users of ClaimSecure web services.
Download

 

Dental

To be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download
 

Drug

To be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download
 

Extended Health Care

To be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download
 

Health Service Spending Account (HSSA)

To be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download
 

Wellness

To be completed when submitting a Wellness claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download

Formulary Select Drug List

List of Formulary Select drugs and alternatives in the same therapeutic class.
Download

 

Eligibility Specifications

An interactive document that contains member/dependant coverage details and data format elements for electronic file submissions.

Download

 

Specialty Drugs and Approval Guidelines

List of Specialty drugs only. These drugs may be classified as "Requires Special Authorization" by the plan sponsor – plan members may download this list and provide it to their Healthcare Providers.
Download
 

Frequently Asked Questions

Answers to frequently asked questions relating the Special Authorization process.
Download
 

Anti-obesity

To be completed when enrolling new employees or changing existing coverage information.
Download
 

Special Authorization Request Standard Form

To be completed when an individual is applying for a drug that requires clinical review prior to approval.
Download
 

Special Authorization Drug List

List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.
Download

 

Custom Knee Brace Questionnaire

To be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Download

 

Hospital Bed Assessment Form

To be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Download

 

Nursing Care Assessment Form

To be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Download

 

Wheelchair Questionnaire

This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Download

Members

TPA Enrollment Form

Used for Third Party Administration (TPA) when enrolling new employees or changing existing coverage information.

Download

 

OAD Eligibility Form

This form is to be completed when enrolling new employees or changing existing coverage information.

Download

 

Dental

To be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download
 

Drug

To be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download
 

Extended Health Care

To be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download
 

Health Service Spending Account (HSSA)

To be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download
 

Wellness

To be completed when submitting a Wellness claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download

Formulary Select Drug List

List of Formulary Select drugs and alternatives in the same therapeutic class.
Download

 

Frequently Asked Questions

Answers to frequently asked questions relating the Special Authorization process.
Download
 

Anti-obesity

To be completed when enrolling new employees or changing existing coverage information.
Download
 

Special Authorization Drug List

List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.
Download
 

Specialty Drugs and Approval Guidelines

List of Specialty drugs only. These drugs may be classified as "Requires Special Authorization" by the plan sponsor – plan members may download this list and provide it to their Healthcare Providers.
Download
 

Special Authorization Request Standard Form

To be completed when an individual is applying for a drug that requires clinical review prior to approval.
Download
 

No Substitution Request

This claim form should be completed when an individual whose plan design includes mandatory generic is applying for coverage for the full cost of the brand name drug.
Download
 

Coverage Navigation Service Enrolment

To be completed when an individual is accessing the coverage navigation service for assistance applying to government and/or manufacturer sponsored programs for Specialty Drug coverage.
Download

 

Custom Knee Brace Questionnaire

To be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval.
Download
 

Hospital Bed Assessment Form

To be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval.
Download
 

Nursing Care Assessment Form

To be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval.
Download
 

Wheelchair Questionnaire

This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.
Download

Advisors

 

OAD Eligibility Form

To be completed when enrolling a new over-age-dependant or changing existing coverage information.
Download
 

TPA Enrollment Form

Used for Third Party Administration (TPA) when enrolling new employees or changing existing coverage information.
Download
 

Web Connectivity Requirements — Existing Client

This document lists minimum hardware and software requirements for users of ClaimSecure web services.
Download

 

Dental

To be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download
 

Drug

To be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download
 

Extended Health Care

To be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download
 

Health Service Spending Account (HSSA)

To be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download
 

Wellness

To be completed when submitting a Wellness claim for reimbursement. Be sure to include the original receipt along with the completed claim form.
Download

Formulary Select Drug List

List of Formulary Select drugs and alternatives in the same therapeutic class.
Download

 

Eligibility Specifications

An interactive document that contains member/dependant coverage details and data format elements for electronic file submissions.

Download

 

Specialty Drugs and Approval Guidelines

List of Specialty drugs only. These drugs may be classified as "Requires Special Authorization" by the plan sponsor – plan members may download this list and provide it to their Healthcare Providers.

Download

 

Frequently Asked Questions

Answers to frequently asked questions relating the Special Authorization process.

Download

 

Anti-obesity

To be completed when enrolling new employees or changing existing coverage information.

Download

 

Special Authorization Request Standard Form

To be completed when an individual is applying for a drug that requires clinical review prior to approval.

Download

 

Special Authorization Drug List

List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.

Download

 

Custom Knee Brace Questionnaire

To be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval.
Download
 

Hospital Bed Assessment Form

To be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval.
Download
 

Nursing Care Assessment Form

To be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval.
Download
 

Wheelchair Questionnaire

This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.
Download

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