Tuesday June 18, 2013

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2013 ESI Medicare Part D High-Income Surcharge Verification

Automatic Bill Payment Authorization Form

GB-01 Enrollment/Change Form

GB-51 General Information

GB-52 Pre-Certification Requirements

GB-53 Almost 65

GB-55 Injury Report

GB-60 Insurance Portability Law (IPL)

GB-79 Flu Vaccination Claim Form

PHI Authorization Form

Provisional Custody by Mandate

Retiree 100 Application

Sample Explanation of Benefits

Flexible Benefits Plan

2013 Flexible Benefits Plan Summary (January 1 - December 31, 2013)

2013 Flexible Spending Arrangement Enrollment Form

2013 Flexible Spending Arrangement Handbook (January 1 - December 31, 2013)

2013 Premium Conversion Enrollment/Stop Form

2013 Request for Change to Flexible Benefits Plan Elections Form

Address or Name Change Form

Dependent Care Flexible Spending Arrangement

Employee Direct Deposit Authorization Form

Flexible Benefits Plan for the State of Louisiana

Flexible Spending Arrangement Card Request Form

GPFSA Medical Expense Claim Reimbursement Form

Health Care Flexible Spending Arrangement Plan Document

Recurring Expense Service Form

Request for Dependent Care Reimbursement Claim Form

HIPAA Privacy

Authorization for Disclosure of Protected Health Information

Notice of Privacy Practices

Privacy Complaint

Request for Access to Protected Health Information

Request for Accounting of Disclosure of Protected Health Information

Request for Amendment of Protected Health Information

Request for Restriction of Protected Health Information

Revocation of Authorization for Use or Disclosure of Health Information

Agencies

GB-74 Designation of OGB Coordinator

GB-75 Designation of Agency Master User

GB-77 Designation of Invoicing Contact

GB-78 Designation of Eligibility/e-Enrollment Contact

HSA Contribution Spreadsheet

Prudential Life Insurance

Administration Manual

Certificate of Insurance

Enrollment Kit (Effective 01/01/2013)

Life Insurance Premiums

Portability Rates

Schedule 1 - Active and Retired Employees Under Age 65 - Effective 1/1/2013

Schedule 2 - Active and Retired Employees Age 65-69 - Effective 1/1/2013

Schedule 3 - Active Employees Age 70 and Over - Effective 1/1/2013

Schedule 4 - Retired Employees Age 70 and Over - Effective 1/1/2013

Life Insurance Assignment of Benefits

Assignment of Value

Assignment to Individual

Assignment to Trustee

Change of Beneficiary and/or Name

Converting Group Term Life Insurance to Individual Insurance

EOI - Agency Instructions

Evidence of Insurability Form (EOI) (To check status of an employee's or dependents EOI, please call (888) 257-0412)

GI Beneficiary Designation/Change

Group Accidental Injury Claim Form (AD&D)

Group Life Insurance Claim Form

Living Benefit Option

Notice of Group Life Conversion Privilege

Portability Election