Employees
Retirees
Wellness

Preventive Screenings
Premium Discount Information View Your Screenings
SEIB Wellness Center Information
SEIB Wellness Center

Screening Locations
ADPH Worksite Screenings SEIB Wellness Center Screenings Participating Wellness Screening Pharmacy Locations
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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Non-Medicare Retirees (Under 65)

Health Insurance Benefits
Stand Alone Policies
Benefit Premiums
Benefit Premium Discounts

Medicare Retirees

Medicare Advantage
Stand Alone Policies
Benefit Premiums
Benefit Premium Discounts

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Requesting a Form 1095-C

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