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  • Wellness

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    Screening Locations

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  • Forms

    Enrollment/Membership

    New Employee Enrollment (IB02) Ineligible Status (IB35) Status Change Form(IB03) Plan Change Form(IB14) Dependent Revoke Election (IB09) Retired Employee Enrollment (IB04) Retiree Employment Verification (IB16) Re-Employed Retiree Enrollment (IB17) Retiree Years of Creditable Coverage Verification (IB18)

    Discount/Waiver Applications

    Non-Tobacco User Discount (IB05) Tobacco Cessation (IB06) Wellness Provider Screening (Take this one to your Doctor) (IB13) Diabetic Eye Exam (Take this one to your Doctor) Employee Spousal Surcharge Waiver Application (IB25) Federal Poverty Level Discount (IB12) Unemployed or Retired Spouse Verification (IB27) Retiree Spousal Surcharge Waiver Application (IB28)

    Flexible Benefits

    2025 Enrollment Form HCRA / DCRA 2026 Enrollment Form HCRA / DCRA Request for Reimbursement DCRA Request for Reimbursement HCRA Qualifying Change in Status Form

    Miscellaneous Forms

    Automatic Draft Payment (IB19) Authorization for Disclosure of Protected Health Information Incapacitated Child Certification Form
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