Forms

Click on the links below to access the Plan Year 2013 forms:

Documentation Required for Proof of Dependency |

SEHP Notice of Privacy Policy

Active State and Non State Employer Group Specific Forms:

• Change Form
• Enrollment Form

Flexible Spending Account (FSA) Forms - Active State Employees ONLY:

• FSA Enrollment/Change Form
• FSA Debit Card Application
• FSA Worksheet
• ASI - FSA Claim Form

Health Savings Account (HSA) Forms:

• HSA Enrollment & Change Form

Direct Bill Specific Forms:

• Direct Bill Enrollment/Change Form
• SEHP - Direct Bill Automated Clearinghouse Enrollment

Affidavit Forms:

• Affidavit of Common Law Marriage
• Affidavit and Application for Coverage of a Permanent and Totally Disabled Dependent Child
• Dependent Grandchild Affidavit

Caremark Forms:

• Caremark Home Delivery Form
• Caremark Reimbursement Claim Form

HealthyKIDS Forms:

• HealthyKIDS Online Enrollment Form

HIPAA Forms:

• HIPAA Authorization Form
• HIPAA Personal Representative Form
• HIPAA Revocation of Personal Representative Form

Misc. Forms:

• Communication Form
• Request for Waiver of 30 Day Waiting Period
• Tax Equity and Fiscal Responsibility Act (TEFRA) Form