Forms and Brochures

• Medical Claim Form
• Rx Claim Form
• Vision Out of Network Claim Form

• HSA SETUP GUIDE 2-99
• Open your Optum HSA Account
• Optum Bank HSA Application

• Group Information Update Form
• HIPAA Disclosure Authorization Form

• Assured Flier
• Charter HMO Flier
• Choice Plus Flier
• Premier PROformance Flier
• Premium Designated Provider Flier
• Select HMO Flier

• COBRA Client Termination Request
• UBES COBRA Administration Guide
• UBES COBRA Change Form
• UBES COBRA Implementation Guide
• UBES COBRA Participant Guide
• UBES COBRA Renewal Guide