CIS Forms
Adoption/Placement
A Certificate of Placement form is required to enroll a child placed in the employee's home for the purpose of adoption, or when a child has been adopted.
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Beneficiary Designation Form
This form can be used to add or change a beneficiary for the life insurance coverage.
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Child Dependent
Affidavit of Dependency form is required to verify dependent eligibility status of unmarried child under the age of 23.
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Domestic Partnership
Certificate of Domestic Partnership form is required for affirmation of domestic partnership.
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Domestic Partnership - Termination
A Termination of Domestic Partnership form is required to terminate a domestic partner from coverage.
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Incapacitated Dependent
Affidavit of Qualifying Incapacitated Dependent Eligibility form is required to certify that your child, who is over the age of 23, is incapacitated due to medical disability, developmental disability or mental disorder.
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ASI Flex - Flexible Spending Accounts (Pre-Tax Plans)
ASI Flex Change Form
Form required to make a mid-year election change to the healthcare or dependent care flexible spending account.
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ASI Flex Claim Form
Reimbursement form for Health Care and Dependent Care expenses.
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ASI Flex Direct Deposit Authorization Form
Authorization form to deposit FSA reimbursements in to your bank account.
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Kaiser
Dental Directory and Member Handbook
This is a generic handbook only. A detailed summary of your coverage was mailed directly to you. If you need specific benefit information, call Kaiser Permanente Customer Service.
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Medical Directory and Member Handbook
This is a generic handbook only. A detailed summary of your coverage was mailed directly to you. If you need specific benefit information, call Kaiser Permanente Customer Service.
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ODS
Benefit Booklet
View/print a benefit booklet at myODS. Login and Password is required.
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Regence BlueCross BlueShield
Benefit Booklet
Print or view a benefit booklet from myRegence. Login and password is required. |
Flu Shot Reimbursement Form
Form to request reimbursement for cost of flu shot.
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HIPAA Release Form
Authorization form to release and disclose protected health information.
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Mail Order Prescription Order Forms
Forms required to set up mail order program with Postal Prescription Services (PPS) or Walgreens.
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Prescription Reimbursement Claim Form
Form to request reimbursement for prescription expenses. (For employees enrolled on Plan V)
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Vision Service Plan
Benefit Coverage
Log on to view coverage information and the last date you or a family member used your vision benefits
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Out of Network Reimbursement Form
Submit this form along with your itemized receipt to VSP for reimbursement.
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