Enrollment Forms:

Dental Benefits Plan Enrollment Application

Claim Forms:

Member Submitted Dental Claim Form

2019 FSA Plan for UCC Ministries Medical Care Expense Claim Form
2019 FSA Plan for UCC Ministries Dependent Care Claim Form
Medical Transportation Expense Certification Form 2018
FSA Plan for UCC Ministries Change in Status Election Form
FSA Plan for UCC Ministries Election Form and Compensation Reduction Agreement Form 2019
FSA Plan for UCC Ministries Election Not to Participate Form
FSA Plan for UCC Ministries Revocation of Benefit Election and Compensation Reduction Agreement Form
Qualifying Dependent Care Expenses Worksheet
Qualifying Medical Care Expenses Worksheet

Certification of Domestic Partner as Dependent or Non-Dependent  
Domestic Partnership Statement of Financial Interdependence Form
Life Insurance (LIDI) Designation of Beneficiary Form
Life Insurance and Disability Income (LIDI) Benefit Plan Enrollment Application
Life Insurance and Disability Income (LIDI) MetLife Enrollment Change Form
MetLife Privacy Notice
Optional Additional Death Benefit Application
Optional Additional Death Benefit Designation of Beneficiary Form
Optional Dependent Death Benefit Application
Statement of Dependent Eligibility Beyond Limiting Age in Plan Due to Mental Retardation, Mental or Physical Handicap
 Statement of Health Form

Enrollment Forms:

Medical Benefits (Non-Medicare) Enrollment
Medicare Supplement Plan Application
Statement of Health Form
Application for Medical Benefits for Adult Children (Under Age 26)

Claim Forms:

Highmark Member Submitted Claim Form(for reimbursement of medical services.)
Highmark Shingles Claim Form(for reimbursement of the Shingles vaccine
BlueCross BlueShield International Claim Form (for reimbursement of foreign medical care only)
Pharmacy Service Claim Form--Please contact Express Scripts at 1.800.939.3781 or log in to your account at www.express-scripts.com to access member submitted pharmacy claim forms.

Other Health Plan Related Forms:

Domestic Partnership Statement of Financial Interdependence Form
Certification of Domestic Partner as Dependent or Non-Dependent
Protected Health Information Release Form

Enrollment Forms:

Vision Benefit Plan Application

Claim Forms:

VSP Out of Network Claim Form