Medical Forms
- Oxford Medical Claim Form
This is the HCFA claim form for all out -of -network medical claims. Please make sure that all Oxford claims are mailed to:
Attn: Claims Department
P.O. Box 29130
Hot Springs, AR 71903
- Exercise Facility Reimbursement Form
Members should use this form each time they visit the gym facility. A facility representative must sign and date this form after each visit. This form should be submitted directly to Oxford at the address listed on the form.
- New York Sports Club (NYSC) Membership Form
- Oxford Enrollment Form
This form should only be completed if you are NOT currently enrolled in Oxford and would like to enroll in individual or family coverage. If you are currently enrolled in the Oxford medial plan, you do NOT have to complete this form. This form must be submitted to the Employee Benefits Department, Queens campus, CCK Building. Do NOT mail this form to Oxford.
- Oxford Addition/Termination/Change Form
This form should be completed if you are adding, terminating, or changing subscribers, spouses, or dependent information. For example: If you wish to add dependents to your plan and/or change from single to family coverage, please complete this form. This form must be submitted to the Employee Benefits Department, Queens campus, CCK Building. Do NOT mail this form to Oxford.
- Coordination of Benefits Form
This form is required for subscribers, spouses or dependents who have additional healthcare coverage. This form should be submitted directly to Oxford at the address listed on the form.
- Student Verification Form
This form is required for subscribers who are enrolling student dependents. This form should be submitted directly to Oxford at the address listed on the form.
- Merck Medco Prescription Drug Reimbursement Form
Oxford Members should use this form for out-of-network pharmacy expenses only, or if they have not received an ID card prior to filling a prescription.
- Merck Medco Home Delivery Pharmacy Service Order Form
Oxford Members should use this form for maintenance prescriptions.
Dental Forms
- UMR (FKA Fiserv Health) Dental Claim Notice
This is the HCFA claim form for all dental claims. Please make sure that all UMR claims are mailed to:
UMR
PO Box 30541
Salt Lake City, UT 84130-0541
- Aetna DMO Enrollment Application (Full Application)
This form should be completed if you wish to enroll or add eligible subscribers, spouses, or dependents for Aetna DMO dental coverage. If you are currently enrolled in the Aetna DMO plan, you do NOT have to complete this form. This form must be submitted to the Employee Benefits Department, Queens campus, CCK Building. Do not mail this form to Aetna.
Supplemental Life Insurance
- Evidence of Insurability Forms
This form should be completed if you elect supplemental life insurance coverage. Please contact the Employee Benefits Office at ext. 2363 for an Evidence of Insurability Form.
- Beneficiary Designation Form
This form should be completed if you would like to change your life insurance beneficiary designation.
Long Term Disability Buy Up
- Evidence of Insurability Form
This form should be completed if you elect optional long term disability coverage. Please contact the Employee Benefits Office at ext. 2363 for an Evidence of Insurability form.
Retirement Plan Forms
Flexible Spending Plan Forms
Qualified Transportation Expense Plan
- Transportation Expense Plan Reimbursement Form
Qualified Transportation Expense Plan members should use this form to request reimbursement for qualified transportation expenses. The form should be faxed, emailed or mailed directly to the vendor, The P&A Group.
- Direct Deposit Authorization Form
Qualified Transportation Expense Plan members should use this form to receive direct deposit of their qualified transportation reimbursements.
- Online Account Access
Instructions from The P&A Group on how to access and manage your online account.
Adoption Assistance Forms
Tuition Exchange Forms