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:
Oxford Health Plans
P.O. Box 7082
Bridgeport, CT 06601-7082
- 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.
-
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