INSTRUCTIONS: ALABAMA PROVIDER SCREENING FORM (Form IB13)

Alabama state employees who choose not to participate in Worksite Wellness screenings may instead submit health screening results through a healthcare provider. This is done using a form IB13. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

Alabama Provider Screening Form IB13 Step 1: Section 1 should be completed by the employee. In the first blank box, enter your name.

Alabama Provider Screening Form IB13 Step 2: In the second blank box, enter the screening date.

Alabama Provider Screening Form IB13 Step 3: In the third blank box, indicate whether you are male or female with a check mark.

Alabama Provider Screening Form IB13 Step 4: In the fourth blank box, enter your age.

Alabama Provider Screening Form IB13 Step 5: In the fifth blank box, enter your contract number.

Alabama Provider Screening Form IB13 Step 6: In the sixth blank box, enter your Social Security number.

Alabama Provider Screening Form IB13 Step 7: In the seventh blank box, enter your date of birth.

Alabama Provider Screening Form IB13 Step 8: In the eighth blank box, enter your daytime telephone number.

Alabama Provider Screening Form IB13 Step 9: Indicate your race or ethnicity with a check mark.

Alabama Provider Screening Form IB13 Step 10: Indicate with a check mark whether you have or have been told you have high cholesterol, high blood pressure or diabetes.

Alabama Provider Screening Form IB13 Step 11: Indicate with a check mark whether you take any medication for the conditions listed in step 10.

Alabama Provider Screening Form IB13 Step 12: The second section should be completed by your health care provider. They will detail your blood pressure, total cholesterol, HDL and LDL cholesterol, triglycerides, blood glucose, height, weight, body mass index, waist measurement, and waist/height ratio.

Alabama Provider Screening Form IB13 Step 13: On the next blank line, the provider should print their name.

Alabama Provider Screening Form IB13 Step 14: On the next blank line, the provider should enter their signature.

Alabama Provider Screening Form IB13 Step 15: On the next blank line, the provider should enter their address.

Alabama Provider Screening Form IB13 Step 16: The completed form should be returned to the State Employees' Insurance Board at the address given at the bottom of the page.

INSTRUCTIONS: ALABAMA WELLNESS DISCOUNT CERTIFICATION FORM (Form IB07)

Alabama state employees who have participated in a worksite wellness screening and have since taken correctly documented steps to control identified health risks may apply for a wellness premium discount on their health insurance coverage by filing a form IB07. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

Alabama Wellness Discount Certification Form IB07 Step 1: In the first blank box, enter the member name.

Alabama Wellness Discount Certification Form IB07 Step 2: In the second blank box, indicate with a check mark whether you are male or female.

Alabama Wellness Discount Certification Form IB07 Step 3: In the third blank box, enter your age.

Alabama Wellness Discount Certification Form IB07 Step 4: In the fourth blank box, enter your contract number.

Alabama Wellness Discount Certification Form IB07 Step 5: In the fifth blank box, enter your Social Security number.

Alabama Wellness Discount Certification Form IB07 Step 6: In the sixth blank box, enter your date of birth.

Alabama Wellness Discount Certification Form IB07 Step 7: In the seventh blank box, enter your daytime telephone number, including the area code.

Alabama Wellness Discount Certification Form IB07 Step 8: Check the first box if you were counseled by a health provider. You must attach either a wellness program office visit referral or a completed provider screening form documenting results. Indicate which with a check mark.

Alabama Wellness Discount Certification Form IB07 Step 9: Check the fourth box if you participated in a Physician Supervised Weight Management program. Enter the name and phone number of the program and the dates on which you attended.

Alabama Wellness Discount Certification Form IB07 Step 10: Check the fifth box if you participated in a SEIB Fitness Center's wellness program. Enter the name and phone number of the program, the dates you attended and a program description.

Alabama Wellness Discount Certification Form IB07 Step 11: Check the sixth box if you self-managed your health risks. You must attach valid proof.

Alabama Wellness Discount Certification Form IB07 Step 12: You must submit this form to the Alabama State Employees' Insurance Board no later than November 30th. Incomplete forms will not be processed and will be returned. Mail the form to the address given at the bottom of the page.

INSTRUCTIONS: ALABAMA COBRA EMPLOYER NOTICE MEMO (Form IB11)

When an Alabama state employee enrolled in the state's SEHIP retirement plan is terminated, dies, has a reduction in hours or becomes eligible for Medicare, their employer must file a form IB11. This form is available on the website maintained by the Alabama State Employees' Insurance Board. Note that instead of filing this memo, you may choose to file a form 11 instead. Further assistance may be obtained by calling the telephone number given at the bottom of the page.

Alabama COBRA Employer Notice Memo IB11 Step 1: On the first blank line, enter the name of the employee.

Alabama COBRA Employer Notice Memo IB11 Step 2: On the second blank line, enter the Social Security number of the employee.

Alabama COBRA Employer Notice Memo IB11 Step 3: On the third blank line, enter the number and street or P.O. box of the employee.

Alabama COBRA Employer Notice Memo IB11 Step 4: On the fourth blank line, enter the city, state and zip code of the employee.

Alabama COBRA Employer Notice Memo IB11 Step 5: On the fifth blank line, enter the name of the employer.

Alabama COBRA Employer Notice Memo IB11 Step 6: If the employee has been terminated for any reason other than gross misconduct, check line 1. Enter the date of their termination.

Alabama COBRA Employer Notice Memo IB11 Step 7: If the employee has had their hours reduced, including a reduction in leave without pay, check line 2. Enter the date on which the reduction took effect.

Alabama COBRA Employer Notice Memo IB11 Step 8: If the employee has died, check line 3. Enter the date of death.

Alabama COBRA Employer Notice Memo IB11 Step 9: If the employee has become eligible for Medicare, check line 4. Enter the date on which they become eligible. Note that this will only affect medical coverage. Dental, prescription or vision care coverage will remain in effect.

Alabama COBRA Employer Notice Memo IB11 Step 10: On the next blank line, enter the date.

Alabama COBRA Employer Notice Memo IB11 Step 11: On the next blank line, the employer should enter their name.

Alabama COBRA Employer Notice Memo IB11 Step 12: Mail the form to the address given at the bottom of the page. You may also fax it to the number given. 

INSTRUCTIONS: ALABAMA STATE EMPLOYEE PLAN CHANGE FORM (Form IB14)

Alabama state employees who wish to change their health insurance coverage do so by filing a form IB14. This form can be obtained from the website of the Alabama State Employees' Insurance Board.

Alabama State Employee Plan Change Form IB14 Step 1: At the top of the form, check the box next to the type of coverage you are seeking to obtain, or indicate if you are declining coverage.

Alabama State Employee Plan Change Form IB14 Step 2: On the first line enter your name, sex and the date on which coverage took effect.

Alabama State Employee Plan Change Form IB14 Step 3: On the second line enter your contact telephone number and date of birth.

Alabama State Employee Plan Change Form IB14 Step 4: On the third line enter your street address.

Alabama State Employee Plan Change Form IB14 Step 5: On the fourth line enter your city, state and zip code.

Alabama State Employee Plan Change Form IB14 Step 6: On the fifth line enter your home and work telephone numbers, as well as your email address.

Alabama State Employee Plan Change Form IB14 Step 7: The next four blank lines are provided to document dependents you are seeking coverage for. This is only required for those seeking basic coverage (SEHIP). On the first line, enter your spouse's name, birthdate and Social Security number.

Alabama State Employee Plan Change Form IB14 Step 8: On the next three lines, enter the same information for your children. Indicate their relationship to you by circling the appropriate label in the second column. 

Alabama State Employee Plan Change Form IB14 Step 9: If you are applying for supplemental coverage or Southland optional policies for vision, dental or cancer care or hospital indemnity, you must complete the last section documenting your primary insurance coverage. The first question asks you if this primary coverage has a spousal carve-out. Indicate "Yes" or "No" by circling the applicable response.

Alabama State Employee Plan Change Form IB14 Step 10: Provide all identifying information required about your health insurance company, as well as any dental coverage you have.

Alabama State Employee Plan Change Form IB14 Step 11: Sign and date the form. Mail it to the address given at the bottom of the second page.

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.