Creating Healthier Benefits
SM
Standard Forms
Other Coverage Verification Form
- Executed online through Citrix's RightSignature
Student Status Form
- Executed online through Citrix's RightSignature
Accident Information Form
- Executed online through Citrix's RightSignature
Authorization For Release Of Information Form
- Executed online through Citrix's RightSignature
Lost Check Agreement
- Executed online through Citrix's RightSignature
Continuity of Care Request Form
Uniform Glossary of Health Coverage and Medical Terms
Medical Claim Form - HCFA 1500
Dental Claim Form
- Executed online through Citrix's RightSignature
Dental Claim Form
Vision Claim Form
- Executed online through Citrix's RightSignature
Vision Claim Form
Disability Claim Form
Section 125 Cafeteria Plans / Flexible Spending Accounts / Health Reimbursement Arrangement
Flexible Spending Account Claim Form
Request Form for Issuance of Additional Flex Debit Cards
Health Reimbursement Arrangement (HRA) Claim Form
Over-the-Counter Medicines - Quick Reference Guide
General Information
No Surprises Act - Understanding your rights and protections from surprise medical bills
COVID-19 OTC Home Test Reimbursement FAQ - Magellan RX Members
COVID-19 OTC Home Test Reimbursement FAQ - Optum RX Members
COVID-19 OTC Home Test Reimbursement FAQ - Southern Scripts Members
COVID-19 OTC Home Test Reimbursement FAQ - CVS Caremark Members
Services Provided by Interactive Medical Systems
Machine Readable Files
Interactive Medical System's Website for Machine Readable Files