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2015 Medicare Part D High-Income Surcharge Verification

Automatic Bill Payment Authorization Form

Blue Cross Appeal Form

GB-01 Enrollment/Change Form

GB-53 Almost 65

GB-55 Injury Report

GB-60 Insurance Portability Law (IPL)

GB-79 Flu Vaccination Claim Form

Health Savings Account (HSA) Payroll Deduction Election Form

Health Savings Account (HSA) Transfer/Rollover Request Form

MedGenerations Rx Claim Form

MedImpact Claim Form

MedImpact Compound Prescription Appeal Form

MedImpact Prescription Appeal Form

PHI Authorization Form

Provisional Custody by Mandate

Retiree 100 Application

Sample Explanation of Benefits

Flexible Benefits Plan

2015 FSA Employee Guide

2015 Flexible Benefits Plan Summary

2015 Flexible Spending Arrangement Enrollment Form

2015 Premium Conversion Enrollment/Stop Form

2015 Recurring Dependent Care Request Form

2015 Request for Change to Flexible Benefits Plan Elections

Address or Name Change Form

Dependent Care Flexible Spending Arrangement

Discovery Benefits - Authorized Representative Form

Discovery Benefits - Benefits Employer Guide

Discovery Benefits - Guide to Substantiating Debit Card Transactions

Discovery Benefits - Guide to filing claims

Discovery Benefits - Guide to the Benefits Debit Card

Flexible Benefits Plan for the State of Louisiana

HEALTH CARE FSA GENERAL NOTICE OF CONTINUATION COVERAGE RIGHTS UNDER COBRA

Health Care Flexible Spending Arrangement Plan Document

HIPAA Privacy

Authorization for Use or Disclosure of Protected Health Information

HIPAA authorization for Dependent Child Medical Information Request Form

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

Participate Calculation Form

REQUEST FOR CONTINUATION OF COVERAGE FOR INCAPACITATED DEPENDENT CHILD

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

Live Better Louisiana

Catapult Expectant Mother Form

Catapult Primary Care Provider Form