Forms
Eligibility Forms for All Plans:
- Insurance Marketplace Coverage Options for Eligible New Hires PY23
- Insurance Marketplace Coverage Options for Eligible New Hires PY24
- Insurance Marketplace Coverage Options for Ineligible New Hires PY23
- Insurance Marketplace Coverage Options for Ineligible New Hires PY24
- Certification of Disabled Dependent Child
- Legal Guardianship Certification
- Release of Information Authorization
- Retiree Benefit Enrollment and Change Form
- Years of Service Form
- Benefit Enrollment and Change Form Unsubsidized
- Travel Pre-Authorization Form
- Travel Reimbursement Form
Appeal Forms:
- External Review Request Form
- Internal Claim Appeal Request Level 2
- Expedited Review
- Physician Certification of Experimental/Investigational Denials Form
Consumer Driven Health Plan (PPO) Forms:
- Express Scripts RX Reimbursement Claim Form
- Express Scripts RX Mail Order Delivery Form
- UMR Medical Claim Form
- Obesity Care Management Initial Evaluation Form
- Diabetes Care Management Form
- HSA Designation of Beneficiary Form
- HRA Reimbursement Request Form
- HSA Direct Transfer Request Form
- Health Savings Account Application and Eligibility Form
- Health Savings Account Direct Transfer Form
Flexible Spending Account Forms:
- Flexible Spending Enrollment Form
- Health Care and Dependent Care Reimbursement Request Form
- Direct Deposit Authorization Form
Health Plan of Nevada (HMO) Forms:
Exclusive Provider Organization Plan (EPO) Forms:
- Express Scripts RX Reimbursement Claim Form
- Express Scripts RX Mail Order Delivery Form
- UMR Medical Claim Form
Low Deductible Plan (PPO) Forms:
- Express Scripts RX Reimbursement Claim Form
- Express Scripts RX Mail Order Delivery Form
- UMR Medical Claim Form
Basic Life Insurance Forms:
United Healthcare is the plan administrator for the basic life insurance policy provided to eligible active and retired members effective 7/1/2022. For basic life insurance death claims where the participant was deceased prior to 7/1/2022 contact The Standard—Customer Service: 1-888-288-1270.
The Standard Insurance Forms for Voluntary Life Insurance:
PEBP Vaccine Clinic Consent Form: