Health Forms:

Form Name	Available Formats (Icon Legend)	Form Descriptions
Blue Cross Health Care Claim Form		To submit health care claims to Blue Cross/Blue Shield.
Financially Interdependent Partners Explanation		To explain and determine FIP eligibility.
Financially Interdependent Partners Statement		To declare FIP eligibility.
FML Leave w/o Pay (FMLWOP), Sick Leave (LWOP) Form		To arrange benefit payments while on LWOP.
FML Request Form		To request leave for a serious health condition (to be completed by employee).
FSA Claim For Medical And Dependent Care Form		To submit a claim for your flexible spending account.
FSA Direct Deposit For Medical And Dependent Care Form		To establish direct deposits of flexible spending account payments.
PharmaCare/Caremark Physician Prior Authorization Request Form (for prescriptions)		To be completed by patient's physician - to request authorization for prescription exceptions (i.e., medication usage past certain time period, specific medication brand, etc.).
PharmaCare/Caremark Prescription Drug Forms	Caremark Site	Site contains reimbursement form for prescription drug claims; site also has other prescription related forms.
Student Enrollment Verification/Dependent Health Care Eligibility		To verify student enrollment and/or to notify employees of dependent (child) health care coverage eligibility.
UA Choice Health Plan Enrollment Form - FY09 Open Enrollment		To enroll employee and dependents in UA health care plan for 7/1/08 through 6/30/09.
UA Choice Health Plan Enrollment Form - FY08		To enroll employee and dependents in UA health care plan for 7/1/07 through 6/30/08.
UA Choice Opt Out Form - FY09 Open Enrollment		To elect to opt out of UA health care coverage as of 7/1/08.
UA Choice Opt Out Form - FY08		To elect to opt out of UA health care coverage and verify proof of other insurance coverage for 7/1/07-6/30/08.
UA Choice Supplemental Benefit Election Form - FY09 Open Enrollment		To add or delete employee selected benefits and/or deductions - i.e., FSA, AD&D, and other employee selected deductions such as accounts payable, parking, United Way, etc. (7/1/08-6/30/09).
UA Choice Supplemental Benefit Election Form - FY08		To add or delete employee selected benefits and/or deductions - i.e., FSA, AD&D, and other employee selected deductions such as accounts payable, parking, United Way, etc. (7/1/07-6/30/08).
VSP Out-of-Network Reimbursement Form		Effective 7/1/04: To submit a claim to VSP (vision vendor) for out-of-network provider reimbursements.

Please email syhr about any problems with this page   21-Apr-2008

  Photo credits: woman in field class and woman at Sitka campus photos courtesy of UAS; Mt. McKinley photo credit © Rex Melton,
Alaska Division of Tourism; flower photo credit Nile Mueller; aurora photo credit Jan Curtis 2003