ÌÇÐÄvlogÊÓƵ

Health Forms and Resources

Medical - BlueCross BlueShield of Texas

• Medical Claim Form

Prescription - Prime Therapeutics

• Prescription Drug Claim Form
• PrimeMail New Prescription Fax Order Form
• PrimeMail Prescription Order Form

Dental - BlueCross BlueShield of Texas

• Claim Form
• Student Certification

Vision - VSP

• Out-of-Network Claim Form

Flexible Spending Accounts - Discovery Benefits

• Automatic Dependent Care Request Form
• Automatic Orthodontia Request Form
• Direct Deposit Enrollment/Change Form
• Reimbursement Request Form
• Instructions: Request a Debit Card Online
• Medical Necessity Form
• Receipt and Substantiation Form

Health Savings Account - BenefitWallet

• Deposit Slip

Leave of Absence

• Family Medical Leave Act - Certification of Health Provider
• Leave of Absence Form - Staff

Miscellaneous

• Employee Name Change Form
• Termination Form