Forms

Use the links below to print dependent student verification forms, HIPAA authorization forms, reimbursement forms for the Health Care Spending Account (HCSA) or the Dependent Care Advantage Account (DCAA), or instructions for the DCAA reimbursement form

Dependent Student Verification Forms
Emblem Health Dental Plan (PDF)
Davis Vision Plan (PDF)

HIPAA Privacy Protection
HIPAA Authorization Form (PDF)

Flex Spending Account Forms
HCSA Reimbursement Request Form and Instructions (PDF)
DCAA Reimbursement Request Form (PDF)
DCAA Reimbursement Request Form Instructions (PDF)

GHI/Emblem Health Preferred Dental Plan
Dental Claim Form and Instructions (PDF)

Empire Plan
Non-participating provider claim form (PDF)
Last updated 7/3/14

A PDF Reader is required to view files on this page.