Dismemberment and Loss of Sight Form
Domestic Partner Declaration of Dependency for Tax Purposes
Elixir Designation of Personal Representative (English)
Elixir Designation of Personal Representative (Spanish)
2024 Kaiser HIPAA Authorization Form
Kaiser/Kaiser Dual Reimbursement Form
Medical Benefits (Shingles Vaccination, Hearing Aid, CBD Oil, COVID OTC) Reimbursement Form
MedImpact Compound Drug Prior Authorization
MedImpact Drug Reimbursement Claim Form
MedImpact Market Price Drug Exception Request
Notice of Return from Armed Forces
Overage Disabled Dependent Child Medical Benefits Application