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SEIB Forms
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New State Employees
Enrollment/Membership
Enrollment (IB02)
Discount Applications
Tobacco
Non-Tobacco User Discount (IB05)
Tobacco Cessation (IB06)
Wellness
Wellness Provider Screening (Take this one to your Doctor) (IB13)
Spousal Surcharge
Spousal Surcharge Waiver (IB25)
Unemployed or Retired Spouse Verification (IB27)
Federal Poverty Level
Federal Poverty Level Discount (IB12)
Flexible Benefit Forms
2019 Enrollment Form HCRA / DCRA
2020 Enrollment Form HCRA / DCRA
Request for Reimbursement Dependent Care Reimbursement Account
Request for Reimbursement Health Care Reimbursement Account
Qualifying Change in Status Form
Active State Employees
Enrollment/Membership
Plan Change (IB14)
Status Change (IB03)
Dependent Revoke Election (IB09)
Discount Applications
Tobacco/Non-Tobacco
Non-Tobacco User Discount (IB05)
Tobacco Cessation (IB06)
Wellness
Wellness Provider Screening (Take this one to your Doctor) (IB13)
Wellness Post Screening Qualification (IB07)
Spousal Surcharge
Spousal Surcharge Waiver (IB25)
Unemployed or Retired Spouse Verification (IB27)
Federal Poverty Level (FPL)
Federal Poverty Level Discount (IB12)
Flexible Benefit Forms
2019 Enrollment Form HCRA / DCRA
2020 Enrollment Form HCRA / DCRA
Request for Reimbursement Dependent Care Reimbursement Account
Request for Reimbursement Health Care Reimbursement Account
Qualifying Change in Status Form
Retired State Employees
Enrollment/Membership
Eligibility
Retiree Years of Creditable Coverage Verification (IB18)
Enrollment
Enrollment (IB04)
Membership Updates
Plan Change (IB14)
Retiree Employment Verification (IB16)
Re-Employed State Retiree Enrollment (IB17)
Status Change (IB03)
Discount Applications
Tobacco/Non-Tobacco
Non-Tobacco User Discount (IB05)
Tobacco Cessation (IB06)
Wellness
Wellness Provider Screening (Take this one to your Doctor) (IB13)
Wellness Post Screening Qualification (IB07)
Spousal Surcharge
Medicare Eligible Spousal Surcharge Waiver (IB28)
Unemployed or Retired Spouse Verification (IB27)
Federal Poverty Level (FPL)
Federal Poverty Level Discount (IB12)
Claim Forms
BC/BS Expense Claim
ConnectYourCare PCO Manual Claim
ConnectYourCare - How to Set up Recurring Claims on CYC
BC/BS Supplemental Expense Claim
BC/BS Supplemental Claim Electronic Funds Transfer Form
Southland Hospital/Cancer Claim
Southland Dental Claim
Southland Vision Claim
Miscellaneous Forms
Automatic Draft Payment (IB19)
Authorization for Disclosure of Protected Health Information
Agency Forms
COBRA Form 11 (IB11)
Refund Request (IB10)
