Forms and Applications

Accidental Dismemberment or Loss of Sight Claim Form (Rev. 04/07/10)
American Fidelity Health Savings Account Application 
Application for Medicare Supplement With Part D (Rev. 10/03/11) 
Application for Retiree/Vested/Non-Vest/Defer Insurance (Rev. 04/16/12)
Authorization to Disclose HealthChoice Information (Rev. 03/27/12)
Beneficiary Designation Form (Rev. 04/03/12)
Certification of Previous Healthcare Coverage (Rev. 08/30/11)
Change of Address Form (Rev. 04/06/12)
Disability Benefits Beneficiary Designation (Rev. 04/06/12)
Disenrollment Letter and Form - Medicare (Rev. 05/27/09)
HIPAA Complaint Form – Privacy (Rev. 08/03/05)
HIPAA Complaint Form – Other than Privacy (Rev. 08/03/05)
Information Technology Accessibility Complaint Form (Rev. 12/01/10)
Life Insurance Claim Form (Rev. 11/10/11)
Member Audit Form (Rev. 04/15/10)
Pharmacy Request for Coverage Determination – Medicare Part D 
Pharmacy Request for Coverage Redetermination – Medicare Part D
Pharmacy Direct Claim Form for Medicare(Rev. 08/08)
Pharmacy Direct Claim Form for Pre-Medicare and Medicare Supplement without Part D Members (Rev. 04/06)
Premium Auto-draft Letter and Form (Rev. 01/22/08)
Reasonable Alternative Documentation 
Revocation of Authorization to Disclose HealthChoice Information (Rev. 03/15/06)
Vaccine Claim Form and How to Request Coverage for Vaccines - Medicare (Rev. 10/07)
Verification of Insurance Coverage (VOIC) Form (Rev. 04/22/10)