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Concentra Medical Records Transfer Forms
Release of Information (English)
Release of Information English.pdf
132.59 KB
(Last Modified on April 26, 2019)
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Release of Information (Spanish)
Release of Information Spanish.pdf
158.49 KB
(Last Modified on April 26, 2019)
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Medical Plan Forms
Cigna Medical Claim Form
2018_Cigna_Medical_Claim_Form.pdf
377.43 KB
(Last Modified on August 13, 2018)
Comments (-1)
Aetna Medical 2021
Medical Benefits -Claim Form
medical-claim-form.pdf
2.81 MB
(Last Modified on January 4, 2021)
Comments (-1)
Prescription Drug Program Forms
ESI Express Scripts Claim Form
HISD_2016_ESI_ClaimForm.pdf
75.49 KB
(Last Modified on August 13, 2018)
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Express Scripts Mail Order Form
Mail Order Form.pdf
734.37 KB
(Last Modified on September 29, 2020)
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Express Scripts Fax Order Form
Mail Order Fax Order Form.pdf
47 KB
(Last Modified on September 29, 2020)
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Dental Plan Forms
Cigna Dental Claim Form
HISD_Cigna_Dental_Claim_Form.pdf
726.63 KB
(Last Modified on August 13, 2018)
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Vision Plan Forms
EyeMed Vision Out-of-Network Claim Form
HISD_2016_EYEMED_OON_Claim_Form_-_08_2013.pdf
68.92 KB
(Last Modified on August 13, 2018)
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Flexible Spending Account Forms 2020
FSA Claim Form 2020 (PayFlex)
FSA Claim form 2020.pdf
486.19 KB
(Last Modified on January 8, 2020)
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Flexible Spending Account Forms 2019
Cigna FSA Dependent Claim Form
2018_Cigna_FSA_Dependent_Care_Claim_Form.pdf
614.97 KB
(Last Modified on August 13, 2018)
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Cigna FSA Claim Form
2018_Cigna_FSA_Claim_Form.pdf
616.12 KB
(Last Modified on August 13, 2018)
Comments (-1)
Federal Income Credit for Child and Dependent Day Care Expenses Worksheet
HISD_Dep_Care_taxcredit_worksheet.pdf
7.33 KB
(Last Modified on August 13, 2018)
Comments (-1)
Dependent Day Care FSA Worksheet
HISD_2016_DDC_FSA_Worksheet.pdf
16.17 KB
(Last Modified on August 13, 2018)
Comments (-1)
Healthcare FSA Worksheet
HISD_HCFSA_Worksheet.pdf
21.19 KB
(Last Modified on August 13, 2018)
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Disability Plan Forms
Long Term Disability Conversion Form
HISD_2012_LTD_Conversion-072316.pdf
657.91 KB
(Last Modified on August 13, 2018)
Comments (-1)
Disability Benefit Claim Form and Instructions
HISD_Disability_Form.pdf
767.45 KB
(Last Modified on August 13, 2018)
Comments (-1)
Life and AD&D Insurance Forms
TRS Beneficiary
HISD_2016_TRS_BeneficiaryForm.pdf
183.29 KB
(Last Modified on August 13, 2018)
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Life and AD&D Portability Form
HISD_2012_LifeADD_PortabilityForm-072316.pdf
472.65 KB
(Last Modified on August 13, 2018)
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Employer Certification for Conversion of Life Insurance Form
HISD_2012_MinnesotaLife_LifeADD_ConversionForm-072316.pdf
111.4 KB
(Last Modified on August 13, 2018)
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Life and AD&D Notice of Death Form
HISD_2012_MinnesotaLife_NoticeofDeath-072316.pdf
482.63 KB
(Last Modified on August 13, 2018)
Comments (-1)
Life and AD&D Beneficiary Form
HISD_2012_HISD_Minnesota_Life_Beneficiary-072316.pdf
158.16 KB
(Last Modified on August 13, 2018)
Comments (-1)
Aflac
CAIC Accident Wellness Claim Form
CAIC Accident Wellness Claim Form_Fillable.pdf
438.79 KB
(Last Modified on August 14, 2020)
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CAIC Accident Claim Form
CAIC Accident Claim Form_Fillable_w Instructions.pdf
840.47 KB
(Last Modified on August 14, 2020)
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CAIC Critical Illness Health Screening Form
CAIC Critical Illness Wellness Claim Form.pdf
245.3 KB
(Last Modified on August 14, 2020)
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CAIC Critical Illness Claim Form
CAIC Critical Illness Claim Form_Fillable.pdf
1.04 MB
(Last Modified on August 14, 2020)
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CAIC Hospital Indemnity Claim Form
CAIC Hospital Indemnity Claim Form_Fillable.pdf
1.35 MB
(Last Modified on August 14, 2020)
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CAIC Cancer Wellness Claim Form
CAIC Cancer Wellness Claim Form.pdf
437.73 KB
(Last Modified on August 14, 2020)
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CAIC Cancer Claim Form
CAIC Cancer Claim Form_Fillable.pdf
700 KB
(Last Modified on August 14, 2020)
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Direct Deposit Form
Direct Deposit Form - Aflac.pdf
583.17 KB
(Last Modified on August 10, 2020)
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Aflac Beneficiary Form
AFLAC Beneficiary Form.pdf
125.85 KB
(Last Modified on October 19, 2020)
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Cancer Care Forms
Cancer Claim Form
HISD_2012_Cancer_Claim_Form.pdf
223.39 KB
(Last Modified on November 6, 2020)
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Hospital Indemnity Plan Forms
Hospital Indemnity Claim Form
HISD_2016_Hospital_Indemnity_ClaimForm.pdf
714.32 KB
(Last Modified on November 6, 2020)
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Critical Illness Plan Forms
Critical Illness Claim Form
HISD_2016_Critical_Illness_ClaimForm.pdf
121.34 KB
(Last Modified on November 6, 2020)
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