Forms & Documents

This form is to be completed when enrolling new employees or changing existing coverage information.

OAD Eligibility Form

This form is to be completed when enrolling a new over-age-dependant or changing existing coverage information.

Form is to used for Third Party Administration (TPA) when enrolling new employees or changing existing coverage information.

Web Connectivity Requirements - Existing Client

Document lists minimum hardware and software requirements for users of ClaimSecure web services.

This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Extended Health Care

This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Health Service Spending Account (HSSA)

This form is to be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

This form is to be completed when submitting a Wellness claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Drug Plan Enhancements

Formulary Select Drug List

List of Formulary Select drugs and alternatives in the same therapeutic class.

Special Authorization Forms

Specialty Drugs and Approval Guidelines

List of Specialty drugs only. These drugs may be classified as "Requires Special Authorization" by the plan sponsor – plan members may download this list and provide it to their Healthcare Providers.

Frequently Asked Questions

Answers to frequently asked questions relating the Special Authorization process.

Anti-obesity

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

Special Authorization Request Standard Form

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

Special Authorization Drug List

List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.

Custom Knee Brace Questionnaire

This questionnaire is to be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Hospital Bed Assessment Form

This questionnaire is to be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Nursing Care Assessment Form

This questionnaire is to be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Wheelchair Questionnaire

This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Quickly and easily find all the forms you are looking for on this page. Either browse through the list of forms below or search by using keywords using the search field below. Once you’ve found your form you can download it in PDF format using the “download” link.

Not sure which form you need? You can also search by using keywords.

Enrollment Form

This form is to be completed when enrolling new employees or changing existing coverage information.

OAD Eligibility Form

This form is to be completed when enrolling a new over-age-dependant or changing existing coverage information.

This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Extended Health Care

This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Health Service Spending Account (HSSA)

This form is to be completed when submitting a Wellness claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Drug Plan Enhancements

Formulary Select Drug List

List of Formulary Select drugs and alternatives in the same therapeutic class.

Special Authorization Forms

Frequently Asked Questions

Answers to frequently asked questions relating the Special Authorization process.

Anti-obesity

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

Special Authorization Drug List

List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.

Specialty Drugs and Approval Guidelines

Special Authorization Request Standard Form

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

No Substitution Request

This claim form should be completed when an individual whose plan design includes mandatory generic is applying for coverage for the full cost of the brand name drug.

Coverage Navigation Service Enrolment

This form is to be completed when an individual is accessing the coverage navigation service for assistance applying to government and/or manufacturer sponsored programs for Specialty Drug coverage.

Custom Knee Brace Questionnaire

This questionnaire is to be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Hospital Bed Assessment Form

This questionnaire is to be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Nursing Care Assessment Form

This questionnaire is to be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Wheelchair Questionnaire

This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Not sure which form you need? You can also search by using keywords.

Enrollment Form

This form is to be completed when enrolling new employees or changing existing coverage information.

OAD Eligibility Form

This form is to be completed when enrolling a new over-age-dependant or changing existing coverage information.

TPA Enrollment Form

Form is to used for Third Party Administration (TPA) when enrolling new employees or changing existing coverage information.

Web Connectivity Requirements - Existing Client

Document lists minimum hardware and software requirements for users of ClaimSecure web services.

This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Extended Health Care

This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Health Service Spending Account (HSSA)

This form is to be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

This form is to be completed when submitting a Wellness claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Drug Plan Enhancements

Formulary Select Drug List

List of Formulary Select drugs and alternatives in the same therapeutic class.

Special Authorization Forms

Frequently Asked Questions

Answers to frequently asked questions relating the Special Authorization process.

Anti-obesity

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

Specialty Drugs and Approval Guidelines

Special Authorization Request Standard Form

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

Special Authorization Drug List

List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.

Custom Knee Brace Questionnaire

This questionnaire is to be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Hospital Bed Assessment Form

This questionnaire is to be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Nursing Care Assessment Form

This questionnaire is to be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Wheelchair Questionnaire

This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Not sure which form you need? You can also search by using keywords.

Pharmacy Provider Agreement and Information

Form and Agreement to be signed by pharmacy in order to connect and transmit real time drug claims to ClaimSecure.

Provider Direct Deposit Registration

Form for provider Direct Deposit registration

This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Extended Health Care

This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Health Service Spending Account (HSSA)

This form is to be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

This form is to be completed when submitting a Wellness claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Special Authorization Forms

Special Authorization Drug List

List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.

Custom Knee Brace Questionnaire

This questionnaire is to be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Hospital Bed Assessment Form

This questionnaire is to be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Nursing Care Assessment Form

This questionnaire is to be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Wheelchair Questionnaire

This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Not sure which form you need? You can also search by using keywords.