Forms marked with an asterisk (*) are accessible after login to complete and sign online. When opening the form, enter your email address and the same first and last name you will use to sign the form. Forms with mismatched signatures will not be accepted.
General Enrollment Forms
DMBA Medical, Dental, and Prescription Forms
Medical and Dental Claim Form
|
International Medical and Dental Claim Form
(For reimbursement of services received outside the U.S.)
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U.S. Navitus Prescription Drug Claim Form
(Domestic Claim—Direct Member Reimbursement)
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International Navitus Prescription Drug Claim Form
(Foreign Claim—Direct Member Reimbursement)
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Participant Appeal Form
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Benefit Suggestion Form
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| Provider Nomination Form |
| Provider Review Form |
Claim Information Request
(For accident, injury, or illness) |
COBRA Forms
COBRA Election Form
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Notice of Qualifying Event
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Notice of Second Qualifying Event
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Notice of Disability
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Notice of Cessation of Disability
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Notice of Other Coverage or Medicare Entitlement
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Medicare-related Forms
Flexible Spending Account (FSA) Forms
Health Savings Account (HSA) Forms
Life Benefit Forms
Financial Benefits Forms
Deseret 401(k) Forms
Master Retirement Plan Forms