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. These files can only be viewed with Adobe Acrobat Reader which can be downloaded for free at Adobe.

 Dependent Student Verification Forms

Emblem Health Dental Plan

Davis Vision Plan

HIPAA Privacy Protection

HIPAA Authorization Form

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

Last updated 7/3/14