Forms

If you are an active employee or retiree, please log on to your E-PEBP Portal for detailed information including Plan Year 2022 documents, new voluntary product information, to enroll/make changes, or to access your HealthScope or Express Scripts single sign on accounts.

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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
• Retiree Benefit Enrollment and Change Form 
• Years of Service Form
• Benefit Enrollment and Change Form Unsubsidized

Appeal Forms:

• External Review Request Form
• CDHP Internal Claim Appeal Request Level 2
• CDHP Expedited Review

Consumer Driven Health Plan Forms:

• OTC COVID-19 Testing Kit Reimbursement Form
• 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:

• Flexible Spending Enrollment Form
• Health Care and Dependent Care Reimbursement Form

Health Plan of Nevada (HPN) Forms:

• OTC COVID-19 Testing Kit Reimbursement Form
• Non-Plan Provider Claim Form
• Optum Pharmacy Mail Order Form
• Optum Pharmacy Reimbursement Form

Premier Plan (EPO) Forms:

• OTC COVID-19 Testing Kit Reimbursement Form
• 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

Low Deductible Plan Forms:

• OTC COVID-19 Testing Kit Reimbursement Form
• Express Scripts RX Reimbursement Claim Form
• Express Scripts RX Mail Order Delivery Form
• HealthSCOPE Medical Claim 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:

• Dental Claim Form

Standard Insurance Forms:

• Group Life Conversion Form
• Group Life Portability Form
• Life and Short Term Disability Enrollment Form
• Life Insurance Claim Form
• Short Term Disability Claim Form