Forms - Medical

Health Comp
Flexible Benefits Claim Form		Download and complete this form to recieve reimbursement for expenses from your Flexible Benefits Account.
Group Medical Claim Form		Download and complete this form to submit a medical claim.
Dental Claim Form		Download and complete this form to submit a dental claim.
Advantage 90 Prescription Plan		This document contains information about the Advantage90 90-day retail medication program.
Walgreens Pharmacy Mail Service
Walgreens Registration Form		Download and complete this form to sign up for Walgreens Healthcare Plus program and start getting your prescriptions delivered right to your home. (Form also available online at walgreens.com)
Walgreens Fax Order Form		Existing Walgreens members may use this form to have their doctor fax in a new prescription. (Form also available online at walgreens.com)
View Mail Service Program Flyer		This flyer outlines information on participation in the Walgreens (Certifax) Mail Service Prescription Program. Features a section on benefits, contacting customer service, and ordering procedures.
Vision Service Plan
Out-of-Network Reimbursement Form		Download and complete this form to request reimbursement for eyecare performed by a non-member provider.