DMBA Forms Library

General Enrollment Forms

• Authorization To Disclose Retirement or Life & Accident Benefit Information
• Authorization to Use and/or Disclose Protected Health Information (PHI)
• Declaration of Insurability Form
• Employee Benefit Enrollment Form
• Disability Direct Deposit Authorization form

DMBA Medical, Dental, and Prescription Forms

• Medical & Dental Claim Form
• International Medical & Dental Claim Form (for reimbursement of services obtained outside the United States)
• Member Appeal Form
• Prescription Claim Form (for Coordination of Benefits or prescription expenses prior to July 1, 2022, and not for FSA claims submission)
• Navitus Prescription Drug Claim Form (for prescription expenses beginning July 1, 2022)
• Navitus Foreign Prescription Drug Claim Form
• Claim Information Request (for accident, injury, or illness)
• Member Benefit Suggestion Form
• Retiree Benefit Enrollment Form
• Senior Dental Plan Enrollment Form
• Home Sleep Testing History and Physical Questionnaire
• Home Sleep Study Physician FAX Order
• Provider Review Form
• Provider Nomination Form
• HMO Enrollment Forms

COBRA Forms

• COBRA Election Form
• Notice of Qualifying Event Form
• Notice of Disability Form
• Notice of Cessation of Disability Form
• Notice of Second Qualifying Event Form
• Notice of Other Coverage or Medicare Entitlement Form

Medicare Related Forms

• Medicare Part B Claim Form
• Medicare DME (Durable Medical Equipment) Claim Form

Flexible Spending Account (FSA) Forms

• Flexible Spending Account Healthcare Claim Form
  (can be filled out online before printing)
• Flexible Spending Account Dependent Care Claim Form
  (can be filled out online before printing)
• Flexible Spending Enrollment Form
  (can be filled out online before printing)
• Flexible Spending Direct Deposit Authorization
• Flexible Spending Letter Of Medical Necessity
  (can be filled out online before printing)

Life Benefit Forms

• Beneficiary Designation   
• Supplemental Group Term Life Application
• 24-Hour Accidental Death & Dismemberment Application
• Retiree Supplemental Group Term Life Application
• Retiree Supplemental Group Term Life Application (hired after 4/1/2010)

Financial Benefits Forms

• Beneficiary Form   
• Authorization To Disclose Retirement or Life & Accident Benefit Information

Deseret 401(k) Forms

Master Retirement Plan

• A Guide to Your Payment Options
• Direct Deposit Authorization
• Release of Information - Participant
• Release of Information - Employer
• Automatic Payment Authorization Agreement Form
• W-4P Federal Form (Retirement)
• Request for State of Utah Income Tax Withholding
• A4-P (Retirement – Arizona State Tax Only)
• Withholding Certificate for Pension or Annuity Payments (Retirement – California State Tax Only)
• Idaho W-4 (Retirement – Idaho State Tax Only)