Member forms

Note: Some employers use customized forms or electronic systems. Please check with your Human Resources office before using one of these forms.

Membership forms

• Authorization for Release of InformationRequest authorization for someone else to act on your behalf regarding your medical coverage.
• Cancel Authorized Representative Appointment FormCancel a request to authorize someone else to act on your behalf regarding your medical coverage.
• Change FormMake changes to existing membership. Send this form to your Human Resources office.
• Appeal Filing FormThis form may only be used for the following groups: ABB, Inc, Arkansas Children’s, Inc., ARcare, Bad Boy Mowers , LLC, Bryce Corporation, Central Arkansas Radiation Therapy Institute, Inc., CommonSpirit Health, E. Ritter Communications Holdings, LLC, First Bank Corporation, J.B. Hunt Transport, Inc., Jefferson Hospital Association, Inc., Milam Construction Company, Navistar, Inc., Nucor Corporation , Revolution Sustainable Solutions, LLC, University of Central Arkansas and Windstream Services, LLC.
• Designation of Authorized Appeal Representative
• Designation of Authorized Appeal Representative - Non-ERISA
• Enrollment FormApply for employee coverage through your Human Resources office. Send this form to your Human Resources office.
• Incapacitated Dependent FormThis form is to be submitted for a request of continuation of coverage for dependents with a mental or physical handicap that have exceeded the student age.
• Other Insurance/Coordination of Benefits (COB)Does anyone on your policy have other insurance coverage?