Insurance

Annual Tobacco User Premium Discount Application IB06

  INSTRUCTIONS: ALABAMA ANNUAL TOBACCO USER PREMIUM DISCOUNT APPLICATION (Form IB06)     Alabama state employees who are tobacco users apply for a premium on their insurance using a form
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Non-Tobacco User Discount Application IB05

  INSTRUCTIONS: ALABAMA NON-TOBACCO USER DISCOUNT APPLICATION (Form IB05)     Alabama state employees may apply for a discount on their state-administered health insurance if they are not tobacco users.
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Flexible Spending Accounts Direct Deposit Form

  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
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Request for Reimbursement Form for Flexible Health Care Account

  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
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Request for Reimbursement Form for Flexible Dependent Care Account

  INSTRUCTIONS: REQUEST FOR REIMBURSEMENT PREFERRED DEPENDENT CARE ACCOUNT   Alabama public employees enrolled in the state PEEHIP program and
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Common OTC Meds Eligible for Your Health Care Spending Account –

  INSTRUCTIONS: COMMON OTC MEDS FOR ELIGIBLE HEALTH CARE FSA REIMBURSEMENT   Alabama public employees enrolled in a Flexible Spending
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FPL Application

  INSTRUCTIONS: FEDERAL POVERTY LEVEL ASSISTANCE APPLICATION (FPL)   Alabama public employees who are active or retired members of the
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Refund Request

  INSTRUCTIONS: REFUND REQUEST   Alabama public education employees who are enrolled in the Public Education Employees' Health Insurance Plan
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MedImpact Prior Authorization Request Form

  INSTRUCTIONS: MEDIMPACT MEDICATION REQUEST FORM    Alabama physicians and providers who need to treat a public employee enrolled in
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Hospital Medical Claim Form – Group 61000 and 14000

  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
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