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Forms

Claim Form: Used by you or your doctor, to submit a claim for benefits or a prescription drug reimbursement (for those policies which have MEDCO Rx Discount Program).

MEDCO Claim Form: Used for reimbursement of prescription drugs for those policies using the MEDCO network of pharmacies.

Specific Case Authorization Form: This form gives us permission to discuss a specific medical condition you might have with a designated person of your choice.

Yearly Authorization Form: This form gives us permission to discuss any and all medical conditions you might have with a designated person of your choice, throughout the school year.

Privacy Notice: This form gives you information on how we handle and protect your privacy regarding any medical condition.

Travel Assistance: This brochure gives you information you need to access our Travel Assistance Services when you travel.