FORMS 

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Kaiser Forms:

	Description of Benefits* Enrollment Form / Enrollment Instructions Change Form Student Certification Domestic Partner Affidavit

*Please refer to the Benefits Summary and Enrollment Materials for a complete description of each program.

PacifiCare Forms:

Enrollment Form / Enrollment Instructions

Enrollment Instruction/Q and A

Student Certification

Domestic Partner Affidavit

Credit Card Authorization Form

Mail Order Prescription

Change Request Form

PPO Medical Claim Form

Prescription Claim Form

UnitedHealthCare Enrollment Form and Instructions (HSA PLAN ONLY)

Health Savings Account (HSA) FAQ 

Misc. Forms.

 

Credit Card Authorization Form

Electronic Funds Transfer (EFT) Authorization

Payment Options