Department of Management Services

Forms

Health Insurance Plans
Authorization for Release of Protected Health Information (Adobe PDF Document 217.08 KB)
Pretax Premium Waiver Form (Adobe PDF Document 196.11 KB)
PPO Non-Network Medical Claim Form (Adobe PDF Document 133.37 KB)
SMS and SES Disability Income Plan Certificate (Adobe PDF Document 363.21 KB)
Spouse Program Election Form (Adobe PDF Document 252.95 KB)
Surviving Spouse Election Form (Adobe PDF Document 196.88 KB)
External/Independent Review Form (Adobe PDF Document 481.53 KB)
Expedited External/Independent Review Form (Adobe PDF Document 48.95 KB)

  

FSA and HSA
Authorization for Release of Protected Health Information (Adobe PDF Document 217.08 KB)
Capital Expenditure Worksheet (Adobe PDF Document 102.19 KB)
Chard Direct Deposit Authorization Form (Adobe PDF Document 36.41 KB)
Flexible Spending Account Claim Form (Adobe PDF Document 104.57 KB)
Post–Deductible HRA Verification Form (Adobe PDF Document 594.85 KB)
FSA Options When Employment Ends Form (Adobe PDF Document 366.01 KB)
Health Savings Account Advantage Individual Transfer Form (Adobe PDF Document 114.56 KB)
Letter of Medical Need Form for Medical Reimbursement Accounts (Adobe PDF Document 68.29 KB)
Personal Use Statement (Adobe PDF Document 145.99 KB)
Transaction Dispute Form (Adobe PDF Document 179.05 KB)

  

CVS Caremark
Authorization to Release Information - One Time (English) (Adobe PDF Document 127.55 KB)
Authorization to Release Information - One Time (Spanish) (Adobe PDF Document 123.50 KB)
Authorization to Release Information - Ongoing (English) (Adobe PDF Document 202.42 KB)
Authorization to Release Information - Ongoing (Spanish (Adobe PDF Document 177.49 KB))
CVS Caremark Mail Service Order Form (Adobe PDF Document 512.62 KB)
CVS Caremark State Employees' Prescription Drug Plan Claim Form (Adobe PDF Document 89.20 KB)

  

Life Insurance
Beneficiary Designation and Change Request Form (Adobe PDF Document 674.34 KB)
Group Life Insurance Evidence of Insurability Form (Adobe PDF Document 1,003.82 KB)
Life Insurance Continuation of Coverage Statement (Adobe PDF Document 27.58 KB)