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Health Care Forms

Click on any of the links below to download the corresponding form (in PDF format)

Health Care Assistance Plan (HCAP) Documents

This Plan document describes the provisions of the Health Care Assistance Plan for employees of the Seventh-day Adventist Organizations of the North American Division working in the United States (“Plan”). Please refer to the North American Division Working Policy Y 22 for the supporting general philosophy of this Plan.

2013 Health Care Assistance Plan (HCAP) Document
2013 Summary of Benefits and Coverage (SBC)

2012 Health Care Assistance Plan (HCAP) Document
2011 Health Care Assistance Plan (HCAP) Document

International Documents

BlueCard World Wide Brochure

International Claim Form English - Español

Reimbursement Forms

Claims Reimbursement Request Form

BlueCard PPO Out-of-Network Reimbursement Form

Medco RX Mail Order Form

Medco RX Reimbursement Form

United Concordia Dental Claim Form

United Concordia Dental Claim Form-Arizona Only

United Concordia Dental Claim Form-New York Only

United Concordia Dental Claim Form-Instructions

Eligibility Forms

Verification of Health Care Coverage for Adult Children

HIPAA Consent for Release

Employee Information Change Request Form

Employee Health Care Enrollment Application

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Employee Benefits

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