INSTRUCTIONS: MEDIMPACT MEDICATION REQUEST FORM 

 

Alabama physicians and providers who need to treat a public employee enrolled in the state's PEEHIP program with a Prior Authorization drug must file the document discussed in this article. This form is only to be completed when there is no suitable alternative available. This document can be obtained from the website maintained by the Retirement Systems of Alabama.

 

Medimpact Medication Request Form Step 1: In the first box, write the patient's name.

 

Medimpact Medication Request Form Step 2: In the second box, write the patient's insurance company and contract number.

 

Medimpact Medication Request Form Step 3: In the third box, write the patient's date of birth.

 

Medimpact Medication Request Form Step 4: In the fourth box, write the patient's diagnosis.

 

Medimpact Medication Request Form Step 5: In the fifth box, write the physician's name and specialty.

 

Medimpact Medication Request Form Step 6: In the sixth box, write the physician's telephone number, including area code.

 

Medimpact Medication Request Form Step 7: In the seventh box, write the physician's DEA number.

 

Medimpact Medication Request Form Step 8: In the eighth box, write the physician's fax number, including area code.

 

Medimpact Medication Request Form Step 9: In the ninth box, write the name of the pharmacy used by the patient.

 

Medimpact Medication Request Form Step 10: In the tenth box, write the pharmacy's telephone number, including the area code.

 

Medimpact Medication Request Form Step 11: In the eleventh box, write the name of the drug being requested.

 

Medimpact Medication Request Form Step 12: In the twelfth box, write the quantity per month being requested.

 

Medimpact Medication Request Form Step 13: In the thirteenth box, write the drug dosage.

 

Medimpact Medication Request Form Step 14: In the fourteenth box, write the length of treatment required.

 

Medimpact Medication Request Form Step 15: In the fifteenth box, write the strength of the medication.

 

Medimpact Medication Request Form Step 16: In the sixteenth box, write the dosage form.

 

Medimpact Medication Request Form Step 17: In the seventeenth box, give a detailed explanation of the reason for this medication request.

 

Medimpact Medication Request Form Step 18: In the eighteenth box, give a detailed list of other medications that have been tried which have failed.

 

Medimpact Medication Request Form Step 19: In the nineteenth box, write any other pertinent history concerning this request.

 

INSTRUCTIONS: HOSPITAL MEDICAL CLAIM FORM – GROUP #61000 AND #14000

 

Alabama public employees enrolled in BlueCross/BlueShield groups 61000 and 14000 use the claim form discussed in this article to seek payment for services provided by a physician or pharmacy. This document can be obtained from the website maintained by the Retirement Systems of Alabama.

 

Hospital Medical Claim Form – Group #61000 And #14000 Step 1: In box 1, enter the patient's last name, first name and middle initial.

 

Hospital Medical Claim Form – Group #61000 And #14000 Step 2: In box 2, enter the patient's contract number as shown on their identification card. If there are any letters in this contract number, include them.

 

Hospital Medical Claim Form – Group #61000 And #14000 Step 3: In box 3, enter the patient's group number as shown on their card or their place of employment.

 

Hospital Medical Claim Form – Group #61000 And #14000 Step 4: In box 4, enter the patient's date of birth.

 

Hospital Medical Claim Form – Group #61000 And #14000 Step 5: In box 5, indicate the patient's sex with a check mark.

 

Hospital Medical Claim Form – Group #61000 And #14000 Step 6: In box 6, indicate with a check mark the patient's relationship to the contract holder.

 

Hospital Medical Claim Form – Group #61000 And #14000 Step 7: In box 7, give the contract holder's name as shown on their identification card, street address, city, state, zip code and daytime telephone number, including any applicable extension.

 

Hospital Medical Claim Form – Group #61000 And #14000 Step 8: If the patient is covered under any other group health insurance form or is entitled to Medicare benefits, box 8 should be completed. Otherwise, leave this box blank.

 

Hospital Medical Claim Form – Group #61000 And #14000 Step 9: In box 9, indicate with check marks whether the condition being treated was related to the patient's employment, an auto accident or another type of accident or injury. If yes, give the date on which the accident occurred or illness began.

 

Hospital Medical Claim Form – Group #61000 And #14000 Step 10: In box 10, give the patient's diagnoses.

 

Hospital Medical Claim Form – Group #61000 And #14000 Step 11: In box 11, give the ordering physician's phone number, name and address. Sign and date the form.

 

INSTRUCTIONS: FLEXIBLE SPENDING ACCOUNT ENROLLMENT APPLICATION 

 

Alabama public employees who are active members of the state-administered PEEHIP health insurance plan can use the application discussed in this article to enroll in a flexible spending account. You may obtain this from the website maintained by the Retirement Systems of Alabama. You may also enroll online via this website.

 

Flexible Spending Account Enrollment Application Step 1: The first section concerns subscriber information. Enter your Social Security or PID number in the first box.

 

Flexible Spending Account Enrollment Application Step 2: Enter your first name in the second box.

 

Flexible Spending Account Enrollment Application Step 3: Enter your middle name or initial in the third box.

 

Flexible Spending Account Enrollment Application Step 4: Enter your last name in the fourth box.

 

Flexible Spending Account Enrollment Application Step 5: Enter your mailing address in the fifth box.

 

Flexible Spending Account Enrollment Application Step 6: Enter your city in the sixth box.

 

Flexible Spending Account Enrollment Application Step 7: Enter your state in the seventh box.

 

Flexible Spending Account Enrollment Application Step 8: Enter your zip code in the eighth box.

 

Flexible Spending Account Enrollment Application Step 9: Enter your date of birth in the ninth box.

 

Flexible Spending Account Enrollment Application Step 10: Enter your home phone number in the tenth box.

 

Flexible Spending Account Enrollment Application Step 11: Enter your work phone number in the eleventh box.

 

Flexible Spending Account Enrollment Application Step 12: Enter your email address in the twelfth box.

 

Flexible Spending Account Enrollment Application Step 13: The next section concerns enrolling in a healthcare flexible spending account. Indicate whether or not you wish to enroll with a checkmark. If yes, indicate whether you wish to apply for a Flex Debit Card, a Traditional Reimbursement, or a Manual Reimbursement. 

 

Flexible Spending Account Enrollment Application Step 14: Enter your monthly contribution amount. Multiply this by 12 to determine to your annual contribution amount.

 

Flexible Spending Account Enrollment Application Step 15: The next section is for those who wish to apply for a Dependent Care Flexible Spending Account. Indicate whether or not you wish to do so with a check mark. Enter your monthly contribution amount and multiply it by 12 to determine your annual contribution account.

 

Flexible Spending Account Enrollment Application Step 16: Sign and date the bottom of the form.

 

INSTRUCTIONS: FLEXIBLE SPENDING ACCOUNT STATUS CHANGE

 

Alabama public employees who have enrolled in the flexible spending account program of the state's PEEHIP health insurance fund can use the form discussed in this article to document a change in their account status. This document can be obtained from the website maintained by the Retirement Systems of Alabama.

 

Flexible Spending Account Status Change Step 1: The first section concerns subscriber information. Enter your PID or Social Security number in the first box.

 

Flexible Spending Account Status Change Step 2: Enter your first name in the second box.

 

Flexible Spending Account Status Change Step 3: Enter your middle name or initial in the third box.

 

Flexible Spending Account Status Change Step 4: Enter your last name in the fourth box.

 

Flexible Spending Account Status Change Step 5: Enter your mailing address in the fifth box.

 

Flexible Spending Account Status Change Step 6: Enter your city in the sixth box. 

 

Flexible Spending Account Status Change Step 7: Enter your state in the seventh box.

 

Flexible Spending Account Status Change Step 8: Enter your zip code in the eighth box.

 

Flexible Spending Account Status Change Step 9: Enter your date of birth in the ninth box.

 

Flexible Spending Account Status Change Step 10: Enter your home phone number in the tenth box.

 

Flexible Spending Account Status Change Step 11: Enter your work phone number in the eleventh box.

 

Flexible Spending Account Status Change Step 12: Enter your email address in the twelfth box.

 

Flexible Spending Account Status Change Step 13: Indicate your marital status with a check mark in the thirteenth box.

 

Flexible Spending Account Status Change Step 14: In the next question, place a check mark next to all statements describing the change in your status being documented. Enter the date on which the event in question occurred.

 

Flexible Spending Account Status Change Step 15: The next section concerns changes to your health care flexible spending account. Enter your new annual election amount or indicate that you wish to stop payroll deductions.

 

Flexible Spending Account Status Change Step 16: The next section concerns changes to your dependent care flexible spending account information. Enter your new annual election amount or indicate that you wish to stop payroll deductions.

 

Flexible Spending Account Status Change Step 17: Sign and date the bottom of the page.

 

INSTRUCTIONS: FLEXIBLE SPENDING ACCOUNTS DIRECT DEPOSIT AUTHORIZATION FORM

 

Alabama public employees who are enrolled in the state PEEHIP health insurance plan and have a flexible spending account within this plan can use the form discussed in this article to obtain a direct deposit refund from their flexible spending account. This document can be obtained from the website maintained by the Retirement Systems of Alabama.

 

Flexible Spending Accounts Direct Deposit Authorization Form Step 1: Indicate with a check mark whether this pertains to a health policy, a dental policy, or a preferred blue account (FSA, HRA, DCAP).

 

Flexible Spending Accounts Direct Deposit Authorization Form Step 2: Indicate with a check mark whether you wish to add, cancel or change.

 

Flexible Spending Accounts Direct Deposit Authorization Form Step 3: On the first blank line, enter the name of the subscriber.

 

Flexible Spending Accounts Direct Deposit Authorization Form Step 4: On the second blank line, enter the applicable contract number or numbers.

 

Flexible Spending Accounts Direct Deposit Authorization Form Step 5: On the third blank line, enter your daytime phone number, including the area code.

 

Flexible Spending Accounts Direct Deposit Authorization Form Step 6: Indicate with a check mark whether you authorize Blue Cross and Blue Shield of Alabama to make a direct deposit to your checking account, savings account or both.

 

Flexible Spending Accounts Direct Deposit Authorization Form Step 7: On the fourth blank line, enter the name on the account or accounts in question.

 

Flexible Spending Accounts Direct Deposit Authorization Form Step 8: On the fifth blank line, enter the name of the bank.

 

Flexible Spending Accounts Direct Deposit Authorization Form Step 9: On the sixth blank line, enter the ABA routing number of the accounts.

 

Flexible Spending Accounts Direct Deposit Authorization Form Step 10: On the seventh blank line, enter the account number in question.

 

Flexible Spending Accounts Direct Deposit Authorization Form Step 10: Attach a voided check, either in its original form or as a copy.

 

Flexible Spending Accounts Direct Deposit Authorization Form Step 11: At the bottom of the page, provide your signature and the date.

 

Flexible Spending Accounts Direct Deposit Authorization Form Step 12: Mail the form along with the voided check to the address given at the bottom of the page. You may alternately fax these documents to the number given at the bottom of the page.

 

INSTRUCTIONS: REQUEST FOR REIMBURSEMENT FORM FOR FLEXIBLE HEALTH CARE ACCOUNT

 

Alabama public employees who have a flexible health care account within the state's PEEHIP health insurance program and who wish to file a request for reimbursement can do so using the form discussed in this article. This document can be obtained from the website maintained by the Retirement Systems of Alabama.

 

Request For Reimbursement Form For Flexible Health Care Account Step 1: At the top of the form, sign and date where indicated.

 

Request For Reimbursement Form For Flexible Health Care Account Step 2: Section 1 concerns information about the employee. In the first box, enter your first name.

 

Request For Reimbursement Form For Flexible Health Care Account Step 3: In the second box, enter your middle initial.

 

Request For Reimbursement Form For Flexible Health Care Account Step 4: In the third box, enter your last name.

 

Request For Reimbursement Form For Flexible Health Care Account Step 5: In the fourth box, enter the month of your date of birth.

 

Request For Reimbursement Form For Flexible Health Care Account Step 6: In the fifth box, enter the date of your date of birth.

 

Request For Reimbursement Form For Flexible Health Care Account Step 7: In the sixth box, enter the year of your date of birth.

 

Request For Reimbursement Form For Flexible Health Care Account Step 8: In the seventh and eighth boxes, enter your preferred blue account number.

 

Request For Reimbursement Form For Flexible Health Care Account Step 9: In the ninth box, enter your company name.

 

Request For Reimbursement Form For Flexible Health Care Account Step 10: In the tenth box, enter your work phone number.

 

Request For Reimbursement Form For Flexible Health Care Account Step 11: In the eleventh box, enter your home phone number.

 

Request For Reimbursement Form For Flexible Health Care Account Step 12: Section II concerns information about the reimbursement you are seeking. You may seek reimbursement for up to five different instances of care. In the left column for each, fill in the oval next to the type of service you are seeking reimbursement for.

 

Request For Reimbursement Form For Flexible Health Care Account Step 13: In the section on the right, provide all requested information about the type of service you are seeking reimbursement for. Attach all appropriate supporting documentation.

 

 

 

INSTRUCTIONS: REQUEST FOR REIMBURSEMENT PREFERRED DEPENDENT CARE ACCOUNT

 

Alabama public employees enrolled in the state PEEHIP program and who have a flexible account for dependent care can use the form discussed in this article to apply for reimbursement. This document may be obtained from the website maintained by the Retirement Systems of Alabama.

 

Request For Reimbursement Preferred Dependent Care Account Step 1: Section 1 concerns information about the employee. Enter your first name, middle initial and last name on the first line.

 

Request For Reimbursement Preferred Dependent Care Account Step 2: Enter your date of birth and preferred blue account number on the second line.

 

Request For Reimbursement Preferred Dependent Care Account Step 3: Enter your company name on the third line.

 

Request For Reimbursement Preferred Dependent Care Account Step 4: Enter your work and home phone numbers on the fourth line.

 

Request For Reimbursement Preferred Dependent Care Account Step 5: Section 2 concerns documentation of the services for which you are seeking reimbursement. You can document up to four separate instances of dependent care for which you are seeking reimbursement. In the column on the left for each one, fill in the appropriate oval to specify whether you are seeking reimbursement concerning child day care, adult day care, before and after school care, or other eligible dependent care.

 

Request For Reimbursement Preferred Dependent Care Account Step 6: Enter the first name of the dependent.

 

Request For Reimbursement Preferred Dependent Care Account Step 7: Enter the last name of the dependent.

 

Request For Reimbursement Preferred Dependent Care Account Step 8: Enter the date of birth of the dependent.

 

Request For Reimbursement Preferred Dependent Care Account Step 9: Enter the age in years of the dependent.

 

Request For Reimbursement Preferred Dependent Care Account Step 10: Enter the beginning and ending dates during which this care was provided.

 

Request For Reimbursement Preferred Dependent Care Account Step 11: Enter the amount of the cost of the care.

 

Request For Reimbursement Preferred Dependent Care Account Step 12: Total the amount of the cost of care where indicated.

 

Request For Reimbursement Preferred Dependent Care Account Step 13: In section 3, give the provider's name and Social Security number or taxpayer ID.

 

Request For Reimbursement Preferred Dependent Care Account Step 14: Sign and date the bottom of the form.

 

INSTRUCTIONS: COMMON OTC MEDS FOR ELIGIBLE HEALTH CARE FSA REIMBURSEMENT

 

Alabama public employees enrolled in a Flexible Spending Account within the state-administered PEEHIP health insurance plan were eligible for coverage on certain over-the-counter (OTC) medications up to January 1, 2011. This article discusses the document outlining which medications which were eligible for reimbursement from their flexible spending account up to this point. This document can be found on the website maintained by the Retirement Systems of Alabama. Note that this list was not intended to be thoroughly comprehensive.

 

Common OTC Meds For Eligible Health Care FSA Reimbursement Step 1: The first OTC medication listed is allergy medicines.

 

Common OTC Meds For Eligible Health Care FSA Reimbursement Step 2: The second OTC medication listed is antacids.

 

Common OTC Meds For Eligible Health Care FSA Reimbursement Step 3: The third OTC medication listed is anti-diarrhea medication.

 

Common OTC Meds For Eligible Health Care FSA Reimbursement Step 4: The fourth OTC medication listed is anti-itch creams and powders.

 

Common OTC Meds For Eligible Health Care FSA Reimbursement Step 5: The fifth OTC medication listed is aspirin.

 

Common OTC Meds For Eligible Health Care FSA Reimbursement Step 6: The sixth OTC medication listed is cold medications.

 

Common OTC Meds For Eligible Health Care FSA Reimbursement Step 7: The seventh OTC medication listed is cough drops, as well as cough syrups and throat lozenges.

 

Common OTC Meds For Eligible Health Care FSA Reimbursement Step 8: The eighth OTC medication listed is Claritin.

 

Common OTC Meds For Eligible Health Care FSA Reimbursement Step 9: The ninth OTC medication is first aid creams.

 

Common OTC Meds For Eligible Health Care FSA Reimbursement Step 10: The tenth OTC medication listed is laxatives.

 

Common OTC Meds For Eligible Health Care FSA Reimbursement Step 11: The eleventh OTC medication listed is wart removal medications.

 

Common OTC Meds For Eligible Health Care FSA Reimbursement Step 12: The next five OTC medications listed are motion sickness medications, muscle/joint pain relief medications, nicotine gums and patches, pain relievers such as Tylenol and pedialyte.

 

Common OTC Meds For Eligible Health Care FSA Reimbursement Step 13: The next two OTC medications listed are reading glasses and sinus medications or nasal sprays.

 

Common OTC Meds For Eligible Health Care FSA Reimbursement Step 14: The last OTC medications listed are hemorrhoid creams and suppositories and eye drops such as Visine.

 

INSTRUCTIONS: FEDERAL POVERTY LEVEL ASSISTANCE APPLICATION (FPL)

 

Alabama public employees who are active or retired members of the state-administered PEEHIP health insurance plan use the form discussed in this article in order to apply for financial assistance related to having income that qualifies as federal poverty level. This document may be obtained from the website maintained by the Retirement Systems of Alabama.

 

Federal Poverty Level Assistance Application (FPL) Step 1: In the first box, enter your Social Security or PID number.

 

Federal Poverty Level Assistance Application (FPL) Step 2: In the second box, enter your first name.

 

Federal Poverty Level Assistance Application (FPL) Step 3: In the third box, enter your middle name or initial.

 

Federal Poverty Level Assistance Application (FPL) Step 4: In the fourth box, enter your last name.

 

Federal Poverty Level Assistance Application (FPL) Step 5: In the fifth box, enter your mailing street address.

 

Federal Poverty Level Assistance Application (FPL) Step 6: In the sixth box, enter your city.

 

Federal Poverty Level Assistance Application (FPL) Step 7: In the seventh box, enter your state.

 

Federal Poverty Level Assistance Application (FPL) Step 8: In the eighth box, enter your zip code.

 

Federal Poverty Level Assistance Application (FPL) Step 9: In the ninth box, enter your home phone number, including the area code.

 

Federal Poverty Level Assistance Application (FPL) Step 10: In the tenth box, enter your work phone number, including the area code.

 

Federal Poverty Level Assistance Application (FPL) Step 11: Do not fill in the eleventh box. This box is for internal use only.

 

Federal Poverty Level Assistance Application (FPL) Step 12: In the twelfth box, indicate with a check mark whether you are single, married, divorced, legally separated or widowed.

 

Federal Poverty Level Assistance Application (FPL) Step 13: In order to successfully submit this form, you must attach a copy of your federal 1040, 1040A or 1040EZ form from the previous year, as well as copies of all supporting 1099 and W-2 documentation. If you are married but did not file jointly, you must provide the same documentation for your spouse. 

 

Federal Poverty Level Assistance Application (FPL) Step 14: Sign and date the form. Your spouse, if applicable, must do the same.

 

Federal Poverty Level Assistance Application (FPL) Step 15: To continue receiving this assistance, you must reapply every year using this form.

 

INSTRUCTIONS: REFUND REQUEST

 

Alabama public education employees who are enrolled in the Public Education Employees' Health Insurance Plan (PEEHIP) can request a refund from the program related to treatment by filing the form discussed which is discussed in this article. This form can be obtained from the website which is maintained by the Retirement Systems of Alabama.

 

Refund Request Step 1: At the top right-hand corner, indicate whether the patient in question is a retired or active member of PEEHIP.

 

Refund Request Step 2: On the first blank line, enter the name of the employee.

 

Refund Request Step 3: On the second blank line, enter the Social Security number of the employee.

 

Refund Request Step 4: On the third blank line, enter the system in which the employee is enrolled.

 

Refund Request Step 5: On the fourth blank line, specify the dollar amount which you are requesting to have refunded to the member.

 

Refund Request Step 6: On the fifth blank line, specify the dollar amount which you are requesting to have refunded to the system.

 

Refund Request Step 7: On the sixth blank line, enter the month or months which this refund request concerns.

 

Refund Request Step 8: On the seventh blank line, enter the type of coverage or coverages which this refund concerns.

 

Refund Request Step 9: On the eighth and ninth blank lines, provide a written explanation of the reason for which you are requesting a refund.

 

Refund Request Step 10: On the tenth blank line, give the name of the member to whom a refund is to be sent.

 

Refund Request Step 11: On the eleventh blank line, give the street address or P.O. box number of the member.

 

Refund Request Step 12: On the twelfth blank line, give the city, state and zip code of the member.

 

Refund Request Step 13: On the thirteenth blank line, give the name of the system to which the refund should be mailed.

 

Refund Request Step 14: On the fourteenth blank line, give the street address or P.O. box number of the system.

 

Refund Request Step 15: On the fifteenth blank line, give the city, state and zip code of the system.

 

Refund Request Step 16: On the last three blank lines, enter the name of the school system, the date, and the signature of an authorized official.