Forms & Bulletins

HIPPA Forms
	°	HIPPA Privacy Bulletin
	°	HIPPA - Frequently Asked Questions
	°	HIPPA - Carrier Authorization
	°	HIPPA Provider Authorization
	°	PacifiCare HIPPA Authorization Form
Prescription Drug Forms (BCBSM & Unicare)
	°	Medco Home Delivery Pharmacy Order Form
	°	Prescription Drug Reimbursement Form
Vision Forms (SVS)
	°	Application for Benefits (Reimbursement)
	°	Directions for completing the Application for Benefits
Life Insurance
	°	Basic Life Insurance Beneficiary Change Form
	°	Optional Life Insurance Beneficiary Change Form
Other Forms/Information
	°	BCBSM Filing Instruction Sheet (Dental Claims)
	°	Intent to Claim Dependents
	°	Local Medical Leave Procedures
	°	Dentemax Provider List - Tulsa Area
	°	Dentemax Provider List - Oklahoma
	°	Medicare Credible Coverage Letter

Bulletins

Bulletin No.	Description
130	New Claims and Appeal Procedures for Health Care Plans / Notice of HIPAA Privacy Practices
141	Additional Taxable Income – Group Life Insurance Over $50,000
145	RE: Disability Benefits – "20 Day Rule" Requirements


	Adobe Acrobat Reader free software and technical support

Retirees Meeting

September 15