Managed Care Providers

Forms
Medical Claim Form
East Central Illinois Pipe Trades Health and Welfare Fund Supplementary Report
Dental Claim Form
PCP to Specialist Referral Form
HealthSCOPE Vision Care Claim Form
Vision Care Claim Form
Whirlpool Biometric Screening Report Form
Direct Member Reimbursement Form
Obesity Care Management Monthly Engagement Form
HealthSCOPE Vision Care Claim Form
Medical Claim Form
East Central Illinois Pipe Trades Enrollment Form
Dental Claim Form
Medical/Dental Enrollment Form
HealthSCOPE Benefits Coverage Confirmation Form
HIPAA Authorization Form
HealthSCOPE Benefits Direct Deposit Authorization Form
El Paso County Health LifeStyle Reimbursement Application
Medical Claim Form
Whirlpool Retiree Direct Deposit Authorization
Medical Claim Form
Health Claim Form
Benefit Bank Reimbursement Claim Form
Health Care & Dependent Care Reimbursement Request Form
Los Angeles Firemen's Relief Association Medical Claim Form
Whirlpool Retiree Health Reimbursement Affidavit
Flexible Spending Enrollment Form
HSA and Payroll Deduction Enrollment Form
Bricklayers Allied Craftsworkers Gross Loss of Time Benefits Form
HSA Distribution Request Form
HealthSCOPE Benefits Reimbursement Request Form
Non-Minor Dependent Health Information Release Authorization
Medical Claim Form
Medical Claim Form
ADA Dental Claim Form
Authorization to Release Health Information
Dental Claim Form
HSA Contribution Form
HealthSCOPE Vision Care Claim Form
Whirlpool Retiree Health Reimbursement Affidavit
Dental Claim Form
Whirlpool Retiree Wellness Activity Form
Whirlpool Wellness Activity Self Report Form
HSA Rollover Transfer Form
Individual Request for Confidential Communications
HSA Contribution Form
Flexible Spending Account Direct Deposit Authorization Form
HealthSCOPE Vision Care Claim Form
HealthSCOPE Medical Claim Form
Medical Claim Form
Sheet Metal Workers Local 1 Enrollment Form
Whirlpool Retiree Health Reimbursement Request Form
Meal Therapy Reimbursement Form
Health Care & Dependent Care Reimbursement Request Form
HealthSCOPE Benefits Enrollment Form
Vision Care Claim Form
Prenatal Wellness Exam Form
Whirlpool RHSA Withdrawal Authorization
Dental Claim Form
HSA Beneficiary Change Form
HSA and Payroll Deduction Enrollment Form