WCIF - Washington Counties Insurance Fund

Plan Forms & Materials | for Employees
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medical	dental	vision	life	disability
employee assistance	wellness	FSA	HSA	retirees

general
2010 Group Benefit Enrollment & Change Form \| for use by active employees HIPAA Authorization of Release Form Domestic partnership: Affidavit of Domestic Partnership (11/09)) Declaration of Termination of Domestic Partnership (04/06)
medical
Washington Counties Insurance Pool (WCIP)	Group Health Options, Inc.
Medical Claim Form	Physician Selection & Change Form
Find a WCIP Provider > (First Choice Health Network)	Medical & Prescription Drug Claim Form for Reimbursement
How to Become a WCIP Provider > (First Choice Health Network)	Coordination of Benefits Questionnaire
Waiver of WCIP Medical Coverage Form	Mail Order Prescription Transfer Request
Notice of HIPAA Special Enrollment Rights and Consequences of Declining Coverage

WHI Prescription Drug Network \| what's this?
Prescription Drug Claim Form
Formulary \| Alphabetical Listing
Formulary \| Medication Category Listing
Rx Mail Order Enrollment Form
Advantage 90 Pharmacies List
How to Become a WHI Provider >

dental	return to top 5
Washington Dental Service (WDS)	Willamette Dental
Dental Claim Form	Enrollment Brochure
MySmile Web Feature Flyer	Frequently Asked Questions
	Provider List

vision	return to top 5
Vision Service Plan (VSP)
Out-of-Network Reimbursement Form
Laser Vision Care Flyer
Eye Health Management Program Flyer

life	return to top 5
The Standard Insurance Company
Life Claim Form
Accelerated Benefit Claim Form \| Spouse / Dependent Accelerated Benefit Claim Form
Waiver of Premium Claim Form
Beneficiary Designation Form \| Minor Beneficiaries' Payout Options
Portability Form for Basic Life Coverage
Request for Conversion Materials (to convert policy from group to individual)

Voluntary Term Life (VTL)

VTL Enrollment & Change Form
VTL Brochure
Portability Form for Voluntary Term Life Coverage
Medical History Statement / Evidence of Insurability Form Must be completed if applying beyond guarantee issue amount or guarantee issue period.

Voluntary Accidental Death & Dismemberment (VAD&D)

VAD&D Enrollment & Change Form
VAD&D Brochure

disability	return to top 5
The Standard Insurance Company
Guide to the Taxation of Employee Disability Benefits
Medical History Statement / Evidence of Insurability Form Must be completed if applying beyond guarantee issue amount or guarantee issue period.

Long Term Disability (LTD)

LTD Claim Form
Base LTD Plan Summary
Buy-Up LTD Plan Flyer
Buy-Up LTD Plan Brochure
LTD Conversion Summary & Form

Voluntary Short Term Disability (VSTD)

VSTD Claim Form
VSTD Enrollment & Change Form
VSTD Plan Brochure

employee assistance	return to top 5
Magellan Health Services
6-1 Visit Plan
Legal & Financial Services (included with 6-1 Visit Plan)
MagellanHealth.com Flyer

wellness program	return to top 5
Alere \| Live Well at WCIF
2010 Program Flyer

flexible spending account	return to top 5
Zenith Administrators
FSA Medical Expense Claim for Disbursement
FSA Dependent Care Expense Claim for Disbursement
FSA Visa Substantiation Form

health savings account	return to top 5
Zenith Administrators
HSA Brochure
HSA: Questions and Answers for Employees

retirees	return to top 5

see Retiree Plans >

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Plan Forms & Materials | for Employees < back to WCIF/WCIP home

Plan Forms & Materials | for Employees
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