Health Care Forms

Benefits

Health Care Forms

Click on any of the links below to download the corresponding form (in PDF format)

Health Care Assistance Plan (HCAP) Documents

This Plan document describes the provisions of the Health Care Assistance Plan for employees of the Seventh-day Adventist Organizations of the North American Division working in the United States (“Plan”). Please refer to the North American Division Working Policy Y 22 for the supporting general philosophy of this Plan.

2012 HCAP plan Document

2011 HCAP Document

2010 HCAP Document *First Revision*

2010 HCAP Document

2008/2009 HCAP Document *First Revision*

2008/2009 HCAP Document

2007/2008 HCAP Document

International Documents

BlueCard World Wide

International Claim Form English 2010-08

International Claim Form Spanish 2010-08

Reimbursement Forms

Claims Reimbursement Request Form (Updated 2011-08-19)

BlueCard PPO Out-of-Network Reimbursement Form

Medco RX Mail Order Form

Medco RX Reimbursement Form

United Concordia Dental Claim Form

United Concordia Dental Claim Form-AZ Only

United Concordia Dental Claim Form-NY Only

United Concordia Dental Claim Form-Instructions

Eligibility Forms

Verification of Health Care Coverage for Adult Children

HIPAA Consent for Release

Employee Information Change Request Form

Employee Health Care Enrollment Application