Forms

HIPAA Privacy

• Authorization to Release Protected Health Information
• Request for Restriction on Use and Disclosure of Health Care Information and/or Confidential Communication
• Member Record Amendment/Correction

State Members

• Enroll/Change/Cancel — Not for Open Enrollment Use
• New Employee Enrollment
• Retiree Enrollment
• Leave of Absence Enrollment
• Survivor Enrollment
• Terminated Vested Enrollment
• Tobacco-Free Promise
• Quit Tobacco Promise
• Foster Parent Enrollment
• Health Savings Account (HSA) Acceptance/ Change Form
• Automatic Withdrawal
• Notice of Special Enrollment Rights
• Non-Contraception Benefit Option

Highway Patrol, MoDOT & Conservation Members

Dental and Vision Only

• Enroll/Change/Cancel — Not for Open Enrollment Use
• Retiree Enrollment
• Leave of Absence Enrollment
• Survivor Enrollment
• Terminated Vested Enrollment
• Notice of Special Enrollment Rights

Medical Plan

• Anthem Medical Claim Form
• Anthem International Claim Form

COVID-19 Forms

• Vaccination Screening and Consent Authorization

Prescription Drug Plan

• ESI Non-Medicare Claim Form
• ESI Medicare Claim Form

Dental and Vision Plans

• Delta Dental Claim Form
• NVA Claim Form