Department of Management Services

Forms

Health FSA and HSA CVS/caremark Life Insurance
Spouse Program Election Form (Adobe PDF Document 128.80 KB)

Health Savings Account Advantage Individual Transfer Form (Adobe PDF Document 130.79 KB) 

 

CVS/caremark State Employees' Prescription Drug Plan Claim Form (Adobe PDF Document 89.20 KB)

 

Life Insurance Continuation of Coverage Statement (Adobe PDF Document 27.58 KB)

 

Surviving Spouse Election Form (Adobe PDF Document 78.90 KB)

Flexible Spending Account Claim Form (Adobe PDF Document 289.85 KB) 

 

CVS/caremark Mail Service Order Form (Adobe PDF Document 490.90 KB)

 

Group Life Insurance Evidence of Insurability Form (Adobe PDF Document 1,003.82 KB)

 

PPO Non-Network Medical Claim Form (Adobe PDF Document 133.37 KB) 

 

Chard Direct Deposit Authorization Form (Adobe PDF Document 219.64 KB)

 

Authorization to Release Information - One Time - English (Adobe PDF Document 77.40 KB)

 

Beneficiary Designation and Change Request Form (Adobe PDF Document 560.14 KB)

 

Pretax Premium Waiver Form (Adobe PDF Document 70.68 KB)

Letter of Medical Need Form for Medical Reimbursement Accounts (Adobe PDF Document 167.12 KB)

 

Authorization to Release Information - One Time - Spanish (Adobe PDF Document 96.77 KB)

 

 
SMS and SES Disability Income Plan Certificate (Adobe PDF Document 164.90 KB)

Personal Use Statement (Adobe PDF Document 145.99 KB)

 

Authorization to Release Information - Ongoing - English (Adobe PDF Document 136.72 KB) 

 

 
 

FSA Options When Employment Ends Form (Adobe PDF Document 570.94 KB) 

 

 

Authorization to Release Information - Ongoing - Spanish (Adobe PDF Document 129.87 KB) 

 

 
  Transaction Dispute Form (Adobe PDF Document 179.05 KB)    
  Authorization for Release of Protected Health Information (Adobe PDF Document 189.46 KB)    
Capital Expenditure Worksheet (Adobe PDF Document 175.33 KB)