Claim Forms

HEALTH CLAIM FORMS

MEDICAL CLAIM FORM (PDF)  
Submit completed claim forms to the address on your ID card.

SUBMIT OUT OF NETWORK HEALTH CLAIM

DENTAL CLAIM FORM (PDF)  
Use this form if you are billed by your dentist. In some cases, your dentist office will submit a claim for you. But if the dentist office bills you directly, you may submit the claim using this standard form. Submit completed claim forms to the address on the back of your ID card.

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SAVINGS & REIMBURSEMENT ACCOUNT CLAIM FORMS
If you have a Flexible Spending Account(FSA) and Health Reimbursement Account(HRA), you can submit your claim and eligible expenses. To determine if the expenses you wish to submit are eligible, follow the steps below.
Step 1:    Review Eligible Expenses: 2018 FSA Expenses | 2017 FSA Expenses
Step 1:    Review Eligible Expenses: 2017 FSA Expenses | 2016 FSA Expenses
Step 2: Review Do's and Dont's
Step 3:    Submit FSA/HRA Form
If you prefer to submit your eligible expenses in the mail, you can use the hardcopy claim form provided below.
FSA Medical Claim Form
FSA Group Number: 99999
Submit completed claim forms to:
Health Care Account Service Center
P.O. Box 981506
El Paso, TX 79998-1506
Fax: 866-262-6354
AUTHORIZATION FOR RELEASE OF INFORMATION ONLINE SUBMISSION FORM

Release of Information form

Member must complete the release of information form, include all necessary documentation and electronically sign before information will be sent to a third party (i.e. physician’s office or insurance company) or discussed with an individual designated by you.

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