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Newnan, Georgia

 

Please submit your completed form and any supporting documentation required to the address indicated on the form.


Enrollment/Change Forms (Medical, Dental, and Vision)

 

Enrollment Form

Submit this form to add a new employee’s coverage selections to your plan. Electronic forms are also available through the client log in.

 

Change of Status Form
Submit this form to change information regarding an employee’s coverage or personal information. Electronic forms are also available through the client log in.

 


Claim Forms (Medical, Dental, and Vision)

 

Health Benefits Claim Form
Submit this form for a medical claim.

 

Dental Benefits Claim Form
Submit this form for a dental claim.

 

Vision Claim Form
Submit this form for a vision claim.

 


Direct Reimbursement Benefit Plans (DRBP)

 

Direct Reimbursement and Direct Assignment Enrollment Form

Submit this form to add a new employee's coverage selections to your plan.

 

Direct Reimbursement and Direct Assignment Orthodontia Claim Form

Submit an orthodontia claim under your DRBP.

 

Direct Reimbursement and Direct Assignment Dental or Vision Claim Form

Submit a dental or vision claim under your DRBP.

 


Flexible Spending Accounts (FSA)

 

Flexible Spending Account (FSA) Health/Dependent Care Enrollment Form
Submit this form to add a new employee to this benefit.

 

Flexible Spending Account (FSA) Health Care Reimbursement Claim Form
Submit this form for reimbursement of health care expenses.

 

Flexible Spending Account (FSA) Dependent Care Reimbursement Claim Form

Submit this form for reimbursement of dependent care expenses.

 

Flexible Spending Account (FSA) Health Reimbursement Arrangement (HRA) Combination Claim Form

Submit this form for reimbursement of dependent care, HRA, or health care expenses.

 

Request for Additional (Dependent) Flex Convenience Card

Submit this form if you would like an additional card for a spouse and/or child. Please complete one form per card requested.

 

Flexible Spending Account (FSA) Letter of Medical Necessity

Submit this form to verify a medical necessity for an expense filed under your Flexible Spending Account (FSA).

 

Flexible Spending (FSA) - Orthodontia Reimbursement Instructions

Submit this form for Orthodontic reimbursement.

 

Flexible Spending Account (FSA) Recurring Expense Claim Form

Submit this form if there is a recurring dependent care expense.

 

Flexible Spending Account (FSA) and Healthcare Reimbursement Arrangement (HRA) Election Form and Salary Reduction Agreement

Submit this form to enroll in both FSA or DCA and HRA.

 


Health Reimbursement Arrangement (HRA)

 

Health Reimbursement Arrangement (HRA) Election Form

Submit this form to add a new employee's coverage selections to your HRA plan.

 

Health Reimbursement Arrangement (HRA) Claim Form
Submit this form to receive reimbursement from your HRA.