File a claim

Download and use these forms to file a claim

Dental PPO claim

Download a dental PPO policy claim form to submit a claim.

Vision PPO claim

Download a vision PPO policy claim form to submit a claim.

HIPPA authorization form

Claim forms already include HIPAA authorization, but you can find a separate form here.

Multi-policy claim

Use this PDF form to submit a claim.

Continuing disability claim

Submit additional information for your on-going disability claim.

Critical illness claim

You can file a critical illness claim if you or a dependent on your policy has been diagnosed with a covered critical illness.

Dental fee schedule claim

Download a dental fee schedule claim form to submit a claim to HealthPlan Services.

Vision fee schedule claim

Download a vision fee schedule claim form to submit a claim to HealthPlan Services.

Accelerated benefit claim

You can file an accelerated benefit claim by downloading this form. 

Change policy details or keep your coverage after an employment change by using our service forms.