Health Insurance and Optional Enrollment Application

INSTRUCTIONS: ALABAMA HEALTH INSURANCE AND OPTIONAL ENROLLMENT APPLICATION

Alabama public education employees who wish to enroll in the state's health insurance plan known as PEEHIP do so using the form discussed in this article. This document can be obtained from the website of the Retirement Systems of Alabama.

Alabama Health Insurance And Optional Enrollment Application Step 1: Indicate with a check mark whether you are an active member or retired.

Alabama Health Insurance And Optional Enrollment Application Step 2: The first section concerns subscriber information. Enter your Social Security number, full name, mailing address, date of birth, home and work phone numbers, gender, marital status, the name of your employer and school system, your email address and date of employment.

Alabama Health Insurance And Optional Enrollment Application Step 3: Indicate with a check mark whether you or your spouse have made use of tobacco products within the last 12 months.

Alabama Health Insurance And Optional Enrollment Application Step 4: The next section concerns the type of coverage you are seeking. Indicate with a check mark whether you are applying for hospital/medical coverage, supplemental hospital/medical coverage, or a VIVA health plan. If the latter, indicate with a check mark whether you are seeking it as a single person or for a family.

Alabama Health Insurance And Optional Enrollment Application Step 5: Indicate with check marks all additional optional coverages you are seeking and enter your requested effective date.

Alabama Health Insurance And Optional Enrollment Application Step 6: The next section requires anyone seeking family coverage to document their dependents. Enter each dependent's name, Social Security number and date of birth. Indicate their gender and relationship to you with check marks.

Alabama Health Insurance And Optional Enrollment Application Step 7: The next section is to be completed if seeking PEEHIP Supplemental coverage or if you or your dependents currently have other group health, dental or vision coverage in effect.

Alabama Health Insurance And Optional Enrollment Application Step 8: The next section must be completed if you or your dependents are eligible for Medicare.

Alabama Health Insurance And Optional Enrollment Application Step 9: The next section is only for completion by PEEHIP members who retired after September 30, 2005.

Alabama Health Insurance And Optional Enrollment Application Step 10: Sign and date the bottom of the form.

Health Insurance and Optional Status Change

INSTRUCTIONS: ALABAMA HEALTH INSURANCE AND OPTIONAL STATUS CHANGE

Alabama public education employees who are already enrolled in the state insurance program known as PEEHIP can use the form discussed in this article to make changes to their insurance coverage, as well as to certify or change their tobacco usage status. This document can be obtained from the website maintained by the Retirement Systems of Alabama.

Alabama Health Insurance And Optional Status Change Step 1: Indicate with a check mark whether you are an active or retired member.

Alabama Health Insurance And Optional Status Change Step 2: The first section requires information about the subscriber. Enter your Social Security or PID number, full name, date of birth and daytime phone number. Indicate your marital status with a check mark.

Alabama Health Insurance And Optional Status Change Step 3: Indicate with check marks whether you or your spouse have used tobacco in the last 12 months.

Alabama Health Insurance And Optional Status Change Step 4: If you have changed your name or employers, give your new name and/or date of employment transfer.

Alabama Health Insurance And Optional Status Change Step 5: In the next section, indicate with check marks the changes you are requesting to be made.

Alabama Health Insurance And Optional Status Change Step 6: Enter the date you are requesting that the changes take effect.

Alabama Health Insurance And Optional Status Change Step 7: In the next section, indicate with check marks the reason for these requested changes.

Alabama Health Insurance And Optional Status Change Step 8: The next section concerns documentation of dependents and is only to be completed if seeking family coverage.

Alabama Health Insurance And Optional Status Change Step 9: The next section is only to be completed if you have the PEEHIP Supplemental Plan or other currently in effect group health, dental or vision coverage.

Alabama Health Insurance And Optional Status Change Step 10: The next section must be completed if you or your dependents are eligible for Medicare.

Alabama Health Insurance And Optional Status Change Step 11: The next section is only to be completed if you retired after September 30, 2005.

Alabama Health Insurance And Optional Status Change Step 12: Sign and date the bottom of the page. Mail the completed document to the address at the top of the first page.

Southland National Vision Claim Form

INSTRUCTIONS: SOUTHLAND VISION CLAIM FORM

Alabama public employees who are enrolled with Southland Benefit Solutions health insurance use the vision claim form discussed in this article to file for coverage for a vision health appointment. This document can be obtained from the website of Southland Benefit.

Southland Vision Claim Form Step 1: The top half of the form is to be completed by you. In box 1, indicate with a check mark whether you are enrolled with Medicare, Medicaid, a group health plan or other. Give the number of your plan in box 1a.

Southland Vision Claim Form Step 2: Enter the patient's name in box 2. Enter the last name first, followed by the first name and middle initial.

Southland Vision Claim Form Step 3: Enter the patient's birth date in box 3.

Southland Vision Claim Form Step 4: Enter the insured's name in box 4.

Southland Vision Claim Form Step 5: Enter the patient's address in box 5.

Southland Vision Claim Form Step 6: Indicate the patient's relationship to the insured with a checkmark in box 6.

Southland Vision Claim Form Step 7: Enter the insured's street address, city, state, zip code and telephone number including area code in box 7.

Southland Vision Claim Form Step 8: Indicate the patient's status with a checkmark in box 8. Choose from "single," "married," "other," "employed," "full-time student" and "part-time student" as appropriate.

Southland Vision Claim Form Step 9: In boxes 10 through 10d, give the insured's group policy or FECA number, employer's or school name, insurance plan or program name, and indicate if there is another health benefit plan. If so, complete boxes 9 through 9d.

Southland Vision Claim Form Step 10: The patient or an authorized person should sign box 11.

Southland Vision Claim Form Step 11: The insured or an authorized person should sign box 12.

Southland Vision Claim Form Step 12: The remainder of the form should be submitted to the office of the vision physician or supplier in question. This office will be responsible for completing and submitting the form.

Southland Vision Claim Form Step 13: This form must be submitted by the physician or supplier to Southland within 365 days of the date of service. The address to which this form should be submitted can be found at the top of the page.

Southland National Dental Claim Form

INSTRUCTIONS: SOUTHLAND DENTAL CLAIM FORM

Alabama public employees who have dental insurance from Southland Benefit Solutions use the dental claim form discussed in this article after having a dental appointment. This document can be obtained from the website maintained by Southland Benefit.

Southland Dental Claim Form Step 1: In box 1, check all applicable boxes concerning the type of transaction this claim covers.

Southland Dental Claim Form Step 2: In box 2, enter the predetermination/preauthorization number if applicable.

Southland Dental Claim Form Step 3: In box 3, give the name, address, city, state and zip code of your insurance company or dental benefit plan.

Southland Dental Claim Form Step 4: Indicate with a checkmark in box 4 whether you have other dental or medical coverage. If no, skip to box 12.

Southland Dental Claim Form Step 5: If you have other medical or dental coverage, give the name of policyholder or subscriber in box 5, enter their date of birth in box 6, check the box next to their gender in box 7, give their policy or subscriber ID in box 8, the plan or group number in box 9, indicate the patient's relationship to the policyholder in box 10 with a checkmark, and give the company or benefit plan's name, address, city state and zip code in box 11.

Southland Dental Claim Form Step 6: In box 12, enter the policyholder or subscriber name, street address, city, state and zip code for the policy listed in box 3.

Southland Dental Claim Form Step 7: In box 13, give their date of birth.

Southland Dental Claim Form Step 8: In box 14, indicate their gender with a checkmark.

Southland Dental Claim Form Step 9: In box 15, give their policy or subscription identification number.

Southland Dental Claim Form Step 10: In box 16, give the plan or group number.

Southland Dental Claim Form Step 11: Give the employer name in box 17.

Southland Dental Claim Form Step 12: Provide all information requested about the patient in boxes 18 through 23.

Southland Dental Claim Form Step 13: Boxes 24 through 35 should be filled out by the office which performed the services in question.

Southland Dental Claim Form Step 14: The patient or guardian, as well as the subscriber, should sign and date the left hand bottom corner of the page where indicated.

Southland National Indemnity and Cancer Claim Form

INSTRUCTIONS: SOUTHLAND NATIONAL INDEMNITY AND CANCER CLAIM FORM

Alabama public employees who are treated in a hospital or for cancer use the claim form discussed in this article to file a claim for coverage with Southland Benefits. This document can be obtained from the website of the Retirement Systems of Alabama.

Southland National Indemnity And Cancer Claim Form Step 1: Enter the subscriber's name in box 1.

Southland National Indemnity And Cancer Claim Form Step 2: Enter the subscriber's contract number in box 2.

Southland National Indemnity And Cancer Claim Form Step 3: Enter the subscriber's home address in box 3.

Southland National Indemnity And Cancer Claim Form Step 4: Enter the patient's name in box 4.

Southland National Indemnity And Cancer Claim Form Step 5: Enter the patient's date of birth in box 5 and their age in box 6.

Southland National Indemnity And Cancer Claim Form Step 6: Indicate the patient's sex with a checkmark in box 7.

Southland National Indemnity And Cancer Claim Form Step 7: Indicate the patient's relationship to the subscriber with a checkmark in box 8.

Southland National Indemnity And Cancer Claim Form Step 8: Enter the subscriber's home and work phone numbers in box 9.

Southland National Indemnity And Cancer Claim Form Step 9: In box 10, provide a written summary of the type of illness or injury, or the doctor's diagnosis.

Southland National Indemnity And Cancer Claim Form Step 10: Enter the physician's name and address, the name of the hospital if confined, the date of admission and discharge, the date the accident or the sickness began, the date on which the first treatment was administered, and indicate whether the condition was related to an accident or illness. Specify the type of accident or illness.

Southland National Indemnity And Cancer Claim Form Step 11: Sign and date the top half of the form.

Southland National Indemnity And Cancer Claim Form Step 12: Give the form to the supervising doctor. They will fill out the attending physician's statement and return the form to you.

Southland National Indemnity And Cancer Claim Form Step 13: Obtain an itemized copy of the hospital bill and attach it to the claim form.

Southland National Indemnity And Cancer Claim Form Step 14: Mail the form and bill to Southland Benefits Administration via the address given on the second page.

MedImpact Prescription Drug Claim Form

INSTRUCTIONS: MEDIMPACT PRESCRIPTION DRUG CLAIM FORM

Alabama public employees enrolled in the PEEHIP health insurance program use the prescription drug claim form discussed in this article to obtain coverage for their prescription drug purchases. This document can be obtained from the website of the Retirement Systems of Alabama.

MedImpact Prescription Drug Claim Form Step 1: The first section requires information about the primary member or cardholder. In the first two boxes, give their ID number and full name.

MedImpact Prescription Drug Claim Form Step 2: In the next three lines, provide the name of the health plan or insurance, the member's daytime phone number, and the member's evening phone number.

MedImpact Prescription Drug Claim Form Step 3: In the next four boxes, provide the member's street address, city, state and zip code.

MedImpact Prescription Drug Claim Form Step 4: The next section should only be filled out if the patient is not the same as the primary member or cardholder. In the first two boxes, enter the patient's name and date of birth.

MedImpact Prescription Drug Claim Form Step 5: Indicate the patient's relationship to the primary member or cardholder with a checkmark.

MedImpact Prescription Drug Claim Form Step 6: Enter the patient's street address, city, state and zip code in the next four boxes.

MedImpact Prescription Drug Claim Form Step 7: If you have any other coverage, enter its name.

MedImpact Prescription Drug Claim Form Step 8: If you have worker's compensation, stop filling out this form and submit your claims to your employer.

MedImpact Prescription Drug Claim Form Step 9: The next section requires details about all prescriptions relevant to this claim. You may either complete this section yourself and submit it with supporting prescription labels and receipts or have your pharmacist complete this section.

MedImpact Prescription Drug Claim Form Step 10: The claimant should sign the form where indicated at the top of the first page.

MedImpact Prescription Drug Claim Form Step 11: The final section concerns compound prescriptions and can only be completed by a pharmacist.

MedImpact Prescription Drug Claim Form Step 12: When submitting this form, it must be accompanied the original prescription label or receipt. Copies are not acceptable. Submit to the claim and prescription labels or receipts to the address at the top of the first page.

Refund Request IB10

INSTRUCTIONS: ALABAMA REFUND REQUEST (Form IB10)

Alabama government employers can request a refund of premiums paid by their department or an employee by filing a form IB10. The document can be found on the website of the Alabama State Employees' Insurance Board.

Alabama Refund Request IB10 Step 1: Enter the name and number of the agency.

Alabama Refund Request IB10 Step 2: Indicate by checking "yes" or "no" whether the health insurance plan in question is a flex plan.

Alabama Refund Request IB10 Step 3: Enter the name, address and Social Security number of the employee.

Alabama Refund Request IB10 Step 4: Enter the dollar amount of the refund sought and the beginning and ending dates of the applicable coverage period.

Alabama Refund Request IB10 Step 5: You must check the box next to the statement describing why you are requesting a refund. Check the first line if seeking a refund for an employee who was terminated. Give the date of their firing.

Alabama Refund Request IB10 Step 6: If seeking a refund for a retired employee, check the second line and give their retirement date.

Alabama Refund Request IB10 Step 7; If seeking a refund for an employee who began leave without pay, check the third line and give the date on which this occurred.

Alabama Refund Request IB10 Step 8: If seeking a refund for an employee who requested that coverage on themselves or a dependent be dropped, check the fourth line and give the date on which this request was made.

Alabama Refund Request IB10 Step 9: If seeking a refund for a dependent who died, check the fifth line and give their date of death.

Alabama Refund Request IB10 Step 10: If seeking a refund for an employee who died, check the sixth line and give their date of death.

Alabama Refund Request IB10 Step 11: If seeking a refund for a premium paid in error for an employee or dependent, check the seventh line and give the period dates during which these erroneous payments occurred.

Alabama Refund Request IB10 Step 12: If seeking a refund for an employee who changed their full-time status to part-time or vice-versa, check the eighth line and give the date on which this change occurred. If none of the above applies, check the ninth line and provide a written explanation. Sign the bottom of the page.

Retiree Employment Verification IB16

INSTRUCTIONS: ALABAMA RETIREE EMPLOYMENT VERIFICATION FORM (Form IB-16)

Alabama state employees who retire after September 30, 2005 are required to make use of any new employer's health benefit plan for primary coverage if the plan covers at least 50% of expenses. You can continue using state employees' insurance if necessary for supplemental and optional coverage. This form can be obtained from the website of the Alabama State Employees' Insurance Plan.

Alabama Retiree Employment Verification Form IB-16 Step 1: The first question on the reverse side of the letter you receive containing form IB-16 asks if you are currently employed. Check "Yes" or "No." If the latter, you do not need to complete the rest of the form. Sign, date and file the form.

Alabama Retiree Employment Verification Form IB-16 Step 2: On the first blank line of question 1, give your current employer's name.

Alabama Retiree Employment Verification Form IB-16 Step 3: On the second and third lines, give your current employer's address.

Alabama Retiree Employment Verification Form IB-16 Step 4: On the fourth blank line, provide your current employer's phone number including the area code.

Alabama Retiree Employment Verification Form IB-16 Step 5: On the fifth blank line, give the date on which you were hired.

Alabama Retiree Employment Verification Form IB-16 Step 6: Question 2 asks if your employer offers group health insurance. Check "Yes" or "No" as applicable. If the latter, you do not need to answer the remaining questions. Sign, date and file the form.

Alabama Retiree Employment Verification Form IB-16 Step 7: Question 3 asks if your employer contributes half or more of the cost of single health insurance coverage for employees. Check "Yes" or "No" as applicable. If the latter, you do not need to answer the last question. Sign, date and file the form.

Alabama Retiree Employment Verification Form IB-16 Step 8: Question 4 asks if you are eligible for your employer's group health insurance coverage. Check "Yes" or "No" as applicable. If "No," provide a written explanation.

Alabama Retiree Employment Verification Form IB-16 Step 9: Sign and date the form.

Alabama Retiree Employment Verification Form IB-16 Step 10: If your new employer ceases to pay at least 50% of the cost of single coverage, you may apply to re-enroll in the State Employees' Health Insurance Plan.

Retiree Enrollment Form IB04

INSTRUCTIONS: ALABAMA RETIREE HEALTH INSURANCE ENROLLMENT FORM (Form IB04)

Alabama state employees who retire can enroll for health insurance through the state using a form IB04. This document can be obtained from the website maintained by the Alabama State Employees' Health Insurance Program.

Alabama Retiree Health Insurance Enrollment Form IB04 Step 1: Indicate with a check mark whether you are seeking basic SEHIP coverage, dental coverage only from Blue Cross, supplemental Blue Cross coverage, or optional Southland policies concerning vision, dental, cancer and hospital indemnity.

Alabama Retiree Health Insurance Enrollment Form IB04 Step 2: On the first line of the first table, enter your full name and sex.

Alabama Retiree Health Insurance Enrollment Form IB04 Step 3: On the second line, enter your Social Security number and date of birth.

Alabama Retiree Health Insurance Enrollment Form IB04 Step 4: On the third line, enter your street address.

Alabama Retiree Health Insurance Enrollment Form IB04 Step 5: On the fourth line, enter your city, county, state and zip code.

Alabama Retiree Health Insurance Enrollment Form IB04 Step 6: On the fifth line, enter your home and work telephone numbers.

Alabama Retiree Health Insurance Enrollment Form IB04 Step 7: If you are seeking dependent coverage, enter the date on which you request it to take effect.

'Alabama Retiree Health Insurance Enrollment Form IB04 Step 8: The next table requires you to list all dependents. The first line is for your husband or wife if applicable. Give their name in the first column, indicate whether they are your husband or wife with a check mark in the second column, give their date of birth in the third column, and enter their Social Security number in the fourth column.

Alabama Retiree Health Insurance Enrollment Form IB04 Step 9: The remaining lines of this table require the same information for any dependent children.

Alabama Retiree Health Insurance Enrollment Form IB04 Step 10: If you have additional group health insurance coverage, document it below. Indicate with a check mark whether this coverage is Medicare A, Medicare B or another insurance. If the latter, specify the coverage.

Alabama Retiree Health Insurance Enrollment Form IB04 Step 11: List the name of any health insurance and/or dental insurance company, the contract holder, the insurance policy and group numbers, and the providing employer's name. Sign and date the bottom of the page.

Retiree Re-Employed Form

INSTRUCTIONS: ALABAMA RE-EMPLOYED STATE RETIREE HEALTH INSURANCE FORM (Form IB2)

Alabama state employees who retire and are then rehired by the state government can reacquire their state health insurance by filing a form IB2. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 1: Indicate with a check mark if you are filing for basic SEHIP coverage from BlueCross BlueShield or whether you are declining coverage.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 2: On the first blank line, enter your full name and sex.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 3: On the second blank line, enter your Social Security number, date of birth, and (if applicable) Medicare number.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 4: On the third blank line, enter your street address.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 5: On the fourth blank line, enter your city, state and zip code.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 6: On the fifth blank line, enter your home and work telephone numbers.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 7: In the next section, you must detail any dependents for whom you are seeking coverage. On the first line, enter the full name of your husband or wife in the first column, indicate which they are by circling the correct descriptor in the second column, enter their birth date in the third column, and enter their Social Security number in the fourth column.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 8: The remainder of the table for dependents requires you to document sons, daughters, stepsons and stepdaughters. Provide their names, indicate their relationship to you, and enter their dates of birth and Social Security numbers.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 9: If you wish to receive a non-tobacco user discount on your coverage, you must submit a separate Non-Tobacco User Discount Application.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 10: The bottom left corner of the form should be completed by your employer.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 11: Sign and date the bottom right corner of the form.

Insurance

Annual Tobacco User Premium Discount Application IB06

Non-Tobacco User Discount Application IB05