Hospital(s)
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
- Health Claim Form: Use this form to file out-of-network medical claims.
- Other Insurance Coverage Form: Must complete this form to inform Meritain if you carry or do not carry other coverage.
- Authorization for Release of Protected Health Information: Use this form to authorize release of protected health information.
- Physician Nomination Form: If your physician is not in the Aetna network, use this form to nominate your physician to participate in the Aetna provider network.
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
- Guardian Dental Claim Form: Use this form to file an out-of-network dental claim.
Vision
- Guardian Davis Vision Claim Form: Use this form to file an out-of-network Davis vision claim.
- Guardian VSP Claim Form: Use this form to file an out-of-network VSP vision claim.
Flexible Spending Accounts
- WageWorks Healthcare Reimbursement Form: Use this form to request reimbursement for eligible healthcare expenses not paid by insurance.
- WageWorks Dependent Care Reimbursement Form: Use this form to request reimbursement for eligible dependent care expenses not paid by insurance.
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
- Short Term Disability & Family Medical Leave Benefits: This fact sheet provides the steps to file a Short Term Disability and/or FMLA claim.
- Short Term Disability, Long Term Disability, and Family Medical Leave: This fact sheet contains additional information on how to file a claim and the normal claim procedures for Short Term Disability, Long Term Disability, and Family Medical Leave.
- Evidence of Insurability: Click this link to provide additional information needed which will determine whether an applicant will be approved for coverage.
Voluntary Benefits
- LifeLock Identity Theft Brochure
- Combined Accident Plan Brochure
- Combined Critical Illness Brochure: Review these brochures for information on our Combined Accident and Critical Illness Policies. Combined Website Instructions Combined Customer Service is 800-544-9382 – website is www.combined.com
- Combined Accident and Critical Illness Claim Form: Use this form to file a claim for the Combined Accident and Critical Illness Policies
- Combined Wellness Claim Form: Use this form for your calendar year Wellness Benefit with the Accident or Critical Illness Plans
- Fidelity Life Claim Form: Use this form for Life Claims
- Fidelity Long Term Care Claim Form: Use this form to submit Long Term Care Claims
- Reliance Voluntary Short Term Disability: This fact sheet provides the steps to file a Short Term Disability and/or FMLA claim.
- Reliance Voluntary Short Term Disability Highlights: Review this form for information on disability income protection.
- Hyatt Legal Plan: Refer to this brochure for important information and contacts for the Legal Plan. Visit www.legalplans.com for additional information. Click “Thinking About Enrolling” and enter the password: Metlaw or Login if already a member.
- Transamerica Life Insurance (EGUL) Brochure: Informational brochure on additional Life Insurance plan
- Allstate Universal Life Insurance (ULIF) Brochure: Review this brochure for information on the additional Life Insurance provided by Allstate