Hospital(s)
Florence Hospital

Employee Benefit Forms

Use Forms Online to eliminate phone calls, delivery time, and photocopy time and expense. Forms Online is your first stop for self service electronic forms. Select the form you need and print a copy—it’s that easy.

General Employment

  • W-4 (Updated Annually): Use this form to withhold the correct federal income tax from your pay.
  • SS-5: Use this form to apply for a new or a replacement Social Security Card.
  • Direct Deposit Form: Use this form to have your pay deposited directly to your checking or savings account.

Health and Welfare Plan Forms
Meritain Health Forms

Pharmacy

  • OptumRx – Claim Form: Use this form for reimbursement when you have paid full price for a prescription drug order at your pharmacy.
  • OptumRx – Home delivery: Register on the Optum Rx website for information on ordering maintenance drugs for home delivery.  You can order online, your doctor can use ePrescribe, you can call it in or print a form for mailing.
  • How to register for the OptumRx website  – Use the member ID number found on your Meritain medical card
  • OptumRx – Formulary Exclusion List: This is the listing of drugs which are excluded from our Formulary so they are not covered.
  • OptumRx Formulary: This is the listing of drugs covered under the Optum Formulary.
  • OptumRx Specialty Drugs with BriovaRx: BriovaRx will handle all your specialty medication needs.  Call 1-855-427-4682 or visit the BriovaRx.com website.  Their patient care coordinators and pharmacists will work with you to understand and manage your medications and coordinate shipping your medication wherever you need it.

Dental

Vision

Flexible Spending Accounts

Wells Fargo – 401(k) Forms

  • 401(k) Beneficiary Form: Contact Wells Fargo directly via the website or 800 number or use this form to designate beneficiary(ies) for plan and submit completed form to your Human Resources Department.
  • 401(k) Distribution Form: Contact Wells Fargo directly at 800-728-3123 to request the most recent Distribution Form.
  • 401(k) Rollover Contribution Form:Contact Wells Fargo directly at 800-728-3123 to request to roll money from another eligible account to the Wells Fargo account.

Life and Accidental Death and Dismemberment (AD&D)

  • Beneficiary Form: Use this form to designate who will receive the Basic and Supplemental Group Life Insurance proceeds in the event of your death.
  • Notice of Group Life Conversion: This form is to be used only when an eligible person desires to convert employee and/or dependent Basic or Supplemental Group Life Insurance to an individual insurance policy.  Employee must submit form to employer to complete the policyholder section.  After form is completed in full, employee has 31 days following the effective date of termination of insurance to submit to carrier.
  • Supplemental Accidental Death & Dismemberment Benefit (Employee Paid): Use this packet to file a claim for employee paid Accidental Death & Dismemberment benefit.
  • Basic Life & Accidental Death Benefit (Employer Paid) and/or Supplemental Life Benefit ( Employee Paid): Use this form to file a claim for  employer paid Basic Life and Accidental Death & Dismemberment benefit and/or an employee paid Supplemental Life benefit.
  • Group Life Accelerated Benefit: Use this form to file a claim for Basic Life and Supplemental Life to receive part of your Life Insurance which may be payable to you while you are still living if certified as Terminally Ill.
  • Evidence of Insurability: Click this link to provide additional information needed which will determine whether an applicant will be approved for coverage.

Disability

Voluntary Benefits