Forms and Applications

Accidental Dismemberment or Loss of Sight Claim Form (Rev. 04/07/10)
American Fidelity Health Savings Account Application 
Application for Medicare Advantage Prescription Drug (MA-PD) Plan - For 2013 enrollments only.
2013 Application for Medicare Supplement With Part D - For 2013 enrollments only.
Application for Retiree/Vested/Non-Vest/Defer Insurance (Rev. 03/21/13)
Appointment of Representative (Rev. 06/2012)
Authorization to Disclose HealthChoice Information (Rev. 03/18/13)
Beneficiary Designation Form (Rev. 10/12/12)
Certification of Previous Healthcare Coverage (Rev. 08/30/11)
Change of Address Form (Rev. 09/25/12)
Disability Benefits Beneficiary Designation (Rev. 11/15/12)
Disenrollment Letter and Form - Medicare (Rev. 05/27/09)
HIPAA Complaint Form – Privacy (Rev. 10/24/12)
HIPAA Complaint Form – Non-Privacy (Rev. 10/24/12)
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. 09/12)
Premium Auto-draft Letter and Form (Rev. 03/25/13)
Revocation of Authorization to Disclose HealthChoice Information (Rev. 10/24/12)
Verification of Insurance Coverage (VOIC) Form (Rev. 04/22/10)