Accident Questionnaire Retiree Verification Form - ACH Preauthorization Dependent Add Form | If applicable, include copies of other coverage insurance cards This form is used to add a new Dependent. Please complete one Dependent Add Form for each dependent being enrolled on the Plan. Be sure to include any and all supporting documents required. Dependent Coverage/Employment Verification Form ** If your Dependent Child has lost their own medical coverage and is between the ages of 19 and 26. This is the only qualifying event that will enable a dependent over the age of 19 to come back onto the policy after previous termination ** EyeMed Reimbursement Form for Out of Network Claims Health Coverage Responsibility Form | Must be notarized HIPAA Form — Authorization for the Release of Protected Health Information Loss of Time & Enhanced Loss of Time Claim Form Prescription Reimbursement Form | Through Capital Rx Spousal Reimbursement Claim Form | 2026 Reimbursement Claim Form | Please use for: WBA, Gym, and Prescription Coordination of Benefits reimbursement requests
Page Last Updated: Aug 18, 2026 (11:09:33)
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