Forms & Materials | for Employees
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WCIF Enrollment & Eligiblity

• 2009 Group Benefit Enrollment & Change Form (09/08)
• Waiver of Coverage Form (04/06)
  - Notice of HIPAA Special Enrollment Rights and Consequences of Declining Coverage (04/08)

Domestic partner eligibility:
- Understanding Domestic Partner Eligibility (12/05)

• Affidavit of Domestic Partnership (06/08)
• Declaration of Termination of Domestic Partnership (04/06)
   

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Medical PPO | Washington Counties Insurance Pool (WCIP)

• WCIP Medical Claim Form (03/06)
• Provider Nomination Form

Prescription drug network - Walgreens Health Initiatives (WHI): (click here for more information)

• WHI Prescription Drug Claim Form (09/07)
• WHI Formulary (listed alphabetically) (02/09)
• WHI Formulary (listed by medication category) (02/09)
• WHI Rx Mail Order Form (01/08)
• WHI Advantage 90 Pharmacies List  (08/07)

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Medical HMO | Group Health Options

• Group Health Medical & Prescription Drug Claim Form for Reimbursement
• Mail Order Prescription Transfer Request
• Group Health Coordination of Benefits Questionnaire (03/08)
• Physician Selection Change Form

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Dental PPO | Washington Dental Service (WDS)

• WDS Dental Claim Form (01/04)
• WDS MySmile Web Feature Flyer
   

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Dental HMO | Willamette Dental

• Willamette Dental Enrollment Brochure (07/07)
• Willamette Dental Frequently Asked Questions
• Willamette Dental Provider List
   

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Vision | Vision Service Plan (VSP)

• VSP Claim Form (12/07)
• VSP Laser Vision Care Flyer
• VSP Eye Health Management Program Flyer
   

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Life | The Standard

Note:   On January 1st, 2009, all WCIF Life Insurance plans will shift from CIGNA to The Standard.  This will
           happen automatically and will require no paperwork on your part.  For information on how
           CIGNA's basic life plan compares with The Standard's, click here }

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Disability | The Standard
click here for a guide to the taxation of employee disability benefits (03/06)

• Standard Medical History Statement / Evidence of Insurability Form
  - Please fill out if applying beyond guarantee issue amount or guarantee issue period.

Long Term Disability:

• Standard Long Term Disability (LTD) Claim Form (02/07)
   
• Standard Base Long Term Disability Plan Summary (07/07)
• Standard Buy-Up Long Term Disability Plan Summary
• Standard Buy-Up Long Term Disability Plan Brochure (01/08)
• Standard Long Term Disability Conversion Summary & Form (09/02)

Short Term Disability

• Standard Short Term Disability (STD) Online Claim Form
   
• Standard Short Term Disability Enrollment & Change Form
• Standard Short Term Disability Plan Brochure
• Standard Short Term Disability Plan Highlights
   

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Employee Assistance Program | Magellan Health Services

• Magellan Six-Visit Model Flyer (2004)
• Magellan Legal & Financial Services Flyer (2004)
   

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Flexible Spending Account (FSA) &
Health Savings Account (HSA)  | Zenith Administrators

FSA:

• Zenith FSA Medical Expense Claim for Disbursement (12/07)
• Zenith FSA Dependent Care Expense Claim for Disbursement (12/07)
• Zenith FSA Visa Substantiation Form (12/07)

HSA:

• Zenith HSA Brochure
• Zenith HSA: Questions and Answers for Employees
   

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