Plan Forms & Materials | for Employees
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 general  

  2010 Group Benefit Enrollment & Change Form  | for use by active employees

  HIPAA Authorization of Release Form 

  Domestic partnership:

 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

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Washington Dental Service (WDS)



 
Willamette Dental
  Dental Claim Form   Enrollment Brochure
  MySmile Web Feature Flyer   Frequently Asked Questions
 

  Provider List

   
 vision

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Vision Service Plan (VSP)

 

  Out-of-Network Reimbursement Form
  Laser Vision Care Flyer
  Eye Health Management Program Flyer
 
 life

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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

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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

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Magellan Health Services

 

  6-1 Visit Plan
  Legal & Financial Services (included with 6-1 Visit Plan)
   MagellanHealth.com Flyer
 
 wellness program

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Alere | Live Well at WCIF


 

  2010 Program Flyer
 
 flexible spending account

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Zenith Administrators

  FSA Medical Expense Claim for Disbursement
  FSA Dependent Care Expense Claim for Disbursement
  FSA Visa Substantiation Form
 
 health savings account

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Zenith Administrators

  HSA Brochure
  HSA: Questions and Answers for Employees
 
 retirees

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  see Retiree Plans >
 

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