Forms
If you are an active employee or retiree, please log on to your E-PEBP Portal for detailed information including Plan Year 2020 documents, new voluntary product information, to enroll/make changes, or to access your HealthScope or Express Scripts single sign on accounts.
Eligibility Forms for All Plans:
- PY 2021 Insurance Marketplace Coverage Options for Eligible New Hires
- PY 2021 Insurance Marketplace Coverage Options for Ineligible New Hires
- Certification of Disabled Dependent Child
- Legal Guardianship Certification
- Release of Information Authorization
- Flexible Spending Enrollment Form
Appeal Forms:
Consumer Driven Health Plan Forms:
- Diabetes Care Management Form
- Express Scripts RX Reimbursement Claim Form
- Express Scripts RX Mail Order Delivery Form
- HealthSCOPE Medical Claim Form
- HRA Claim Form
- HSA Claim Form
- HSA Beneficiary/Spousal Consent Form
- HSA Contribution Form
- Obesity Care Management Initial Evaluation Form
- Obesity Care Management Meal Therapy Reimbursement Form
- Physician Certification of Experimental/Investigational Denials Form
- Travel Pre-Authorization for Organ/Tissue Transplant or Bariatric Surgery
- Travel Reimbursement Form for Organ/Tissue Transplant/Bariatric Surgery
Flexible Spending Account Forms:
Health Plan of Nevada (HPN) Forms:
Premier Plan (EPO) Forms:
- Express Scripts RX Reimbursement Claim Form
- Express Scripts RX Mail Order Delivery Form
- HealthSCOPE Medical Claim Form
- Expedited Appeal Review
- Internal Claim Appeal Request Level 2
- External Appeal Review Request Level 3
- Obesity Care Management Initial Evaluation Form
- Obesity Care Management Meal Therapy Reimbursement Form
- Physician Certification of Experimental/Investigational Denials Form
- Travel Pre-Authorization for Organ/Tissue Transplant or Bariatric Surgery
- Travel Reimbursement Form for Organ/Tissue Transplant/Bariatric Surgery
Dental Plan Forms:
Standard Insurance Forms:
- Group Life Conversion Form
- Group Life Portability Form
- Life and Short Term Disability Enrollment Form
- Life Insurance Claim Form
- Long Term Disability Claim Form
- Long Term Disability Conversion Form
- Short Term Disability Claim Form
Public Records Request Forms: