CIS Forms
Affidavit of Dependency
Required form to verify dependent eligibility status of unmarried child under the age of 23.
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Affidavit of Qualifying Incapacitated Dependent Eligibility
Use this form 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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Beneficiary Designation Form
This form can be used to add or change a beneficiary for the life insurance coverage.
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Certificate of Domestic Partnership
Required form for affirmation of domestic partnership.
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Certificate of Placement
Required form for placement and adoption of child.
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Termination of Domestic Partnership
Required form to terminate domestic partnership.
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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. |
Direct Reimbursement Claim Form
Form to request reimbursement for prescription expenses. (For employees enrolled on Plan V)
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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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Standard
Medical History Statement
Required form for new employees who are electing voluntary life or spouse life coverage over the guarantee issue amount, or for current employees electing voluntary coverage for the first time or increasing their existing coverage.
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Medical History Statement (California Residents Only)
Required form for new employees who are electing voluntary life or spouse life coverage over the guarantee issue amount, or for current employees electing voluntary coverage for the first time or increasing their existing coverage.
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Group Life Portability Insurance Application
Employees may be eligible to buy portable Group Life Insurance when employment terminates. If the employer's Group Life Insurance plan includes Accidental Death and Dismemberment (AD&D) and/or Dependent Insurance, employees may also be eligible to buy those coverages. The application will provide eligibility requirements and instructions on how to apply.
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LTD (Long Term Disability) Conversion Insurance Application
Terminated employees who were covered under their employer's LTD plan may have a right to buy LTD conversion insurance without submitting Evidence of Insurability. Employees have 31 days after the LTD insurance ends to apply. The application will provide eligibility requirements and instructions on how to apply.
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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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