BA login
|
PEBA
|
privacy
|
disclaimer
|
site map
Search
Home
Contact Us
News & Updates
Updates
Newsletters
HIPAA
FAQ
Links
Plug-Ins
Forms
Coverage & Eligibility
Active Employees
COBRA Subscribers
Retirees
Survivors
Spouses and Children
Local Subdivisions
Claims Information
Retirement Information
Premiums
Publications
Presentations
Tobacco Information
Online Directories
MyBenefits
Prevention Partners
Training Calendar
Newsletters
Coordinators
Resources & Tools
Wellness & Preventive Benefits
Workplace Screenings
Diabetes
Hypertension
Weight Management
About Us
Backgrounder
Facts
50-State Survey
Reduce Your Payments
SC vs US Averages
Benefits Administrator
Employer Eligibility to Participate
Rates
Local Subdivisions
BA Login
Home
> Forms
Forms
Adjust font size
|
Notice of Election
Active Notice of Election (NOE)
- (310KB - PDF)
Active Notice of Election (NOE) - Permanent Part-Time Teacher
- (269KB - PDF)
Retiree Notice of Election
- (265KB - PDF)
COBRA Notice of Election
- (280KB - PDF)
Survivor Notice of Election
- (259KB - PDF)
Health Insurance
Certification Regarding Tobacco Use
- (20KB - PDF)
State Health Plan (SHP)
Health Expenses Claim Form (2 pages)
- (81KB - PDF)
Prescription Drug Claim Form (Coordination of Benefits/Direct) and Instructions - 2 pages
- (134KB - PDF)
Prescription Drug Mail Order Form and Instructions - 2 pages
- (213KB - PDF)
Prescription Drug Health, Allergy & Medication Questionnaire (Complete form the first time you use the mail-order service)
- (56KB - PDF)
BlueCard Worldwide International Claim Form
- (49KB - PDF)
BlueChoice HealthPlan (HMO)
Health Expenses Claim Form - BlueChoice
- (698KB - PDF)
BlueCard Worldwide International Claim Form
- (49KB - PDF)
Dental Insurance
Dental Claim Form and Instructions
- (56KB - PDF)
Vision Care
Out of Network Vision Services Claim Form
- (80KB - PDF)
Request for Medically Necessary Contact Lens Benefit Form
- (75KB - DOC)
Life Insurance
Accelerated Benefits Option Form
- (255KB - PDF)
Accidental Death and Dismemberment Claim Form
- (1.1MB - DOC)
Life Insurance Planner Worksheet
- (1.3MB - PDF)
Statement of Health (interactive version)
- (277KB - DOC)
Statement of Health (printable version)
- (86KB - PDF)
Notice of Group Life Insurance Conversion Privilege Form
- (22KB - PDF)
Continuation of Group Optional Life Coverage Form
- (22KB - PDF)
Beneficiary Designation Form
- (42KB - PDF)
Long Term Disability (LTD) Insurance
Basic Long Term Disability Certificate
- (143KB - PDF)
Supplemental Long Term Disability Certificate
- (185KB - PDF)
Medical History Statement for Late Entrants and Instructions - 3 pages
LTD Benefits Claim Form packet - 16 pages
- (130KB - PDF)
Includes:
Instructions (p.1-2);
Employee's Statement (p.3-6);
Authorization to Obtain Information (p. 7-8);
Authorization to Obtain Psychotherapy Notes (p. 9-10);
Attending Physician's Statement (p. 11-13);
Employer's Statement (p. 13-16);
Request for Long Term Disability Conversion Materials
- (337KB - PDF)
MoneyPlu$
Health Savings Account (HSA) Rollover/Transfer Form
- (350KB - PDF)
MoneyPlu$ Claim Form - 2 pages (interactive version)
- (229KB - PDF)
MoneyPlu$ Claim Form - 2 pages (printable version)
- (126KB - PDF)
2013 MoneyPlu$ Enrollment Form - 2 pages
- (143KB - PDF)
MoneyPlu$ Refusal to Participate Statement
- (21KB - PDF)
MoneyPlu$ Worksheets
- (121KB - PDF)
MoneyPlu$ Direct Deposit Authorization Form and Terms and Conditions for Participating - 2 pages
- (103KB - PDF)
MoneyPlu$ Change in Status Form
- (71KB - PDF)
COBRA
Notice of COBRA Qualifying Event
- (19KB - PDF)
Notice to Extend COBRA Continuation Coverage
- (21KB - PDF)
Notice to Terminate COBRA Continuation Coverage
- (20KB - PDF)
HIPAA
HIPAA Information
Notice of Privacy Practices
- (26KB - PDF)
Authorized Representative Form
- (27KB - PDF)
Request to Inspect and/or Copy Protected Health Information
- (8KB - PDF)
Request to Amend Protected Health Information
- (21KB - PDF)
Request for Accounting of Disclosures
- (8KB - PDF)
Request for Restriction of Use or Disclosure of Protected Health Information
- (22KB - PDF)
Privacy Regulations Complaint Form
- (23KB - PDF)
Request for Confidential Communications
- (33KB - PDF)
Other Forms
Dependent Verification Form (Self Audit)
- (12KB - PDF)
Common Law Marriage Affidavit
- (16KB - PDF)
Employment Verification Record and Instructions - 2 pages
- (59KB - PDF)
Incapacitated Child Certification Form
- (37KB - PDF)
Dependent Social Security Number Form
- (17KB - PDF)
Universal Name/Address Change Form
- (140KB - PDF)
Download Flash here
if you cannot see this movie.