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Enrollment and Status Change Form

Enrollment Form

Dental Only Enrollment Form

Participant Status Change Form

Initial HIPAA Notice

Claim Forms

ADA Claim Form for ACS Dental

Medical Claim Reimbursement Form

Catalyst Direct Reimbursement Form

Forms to Provide Additional Information to Process Claims

Statement of Injury/Illness

Dependent Child Eligibility

Confirmation Of Continued Eligibility Of Dependent Child

Disability Income Claim

Documentation of Other Coverage

Flexible Spending Account - Medical Expenses Reimbursement

Flexible Spending Account - Dependent Care Reimbursement

COBRA Forms

Notice of Qualifying Event

Notice of Second Qualifying Event

Notice of Disability

Notice of Other Coverage, Medicare Entitlement or Cessation of Disability

Privacy Authorization Forms

Member's Authorization Request Form

Subscriber's Authorization for Spouse Request Form

Confidential Communications Request Form

Confidential Communications Change In Alternative Address Request Form

Request To Access Protected Health Information Form

Request To Amend Protected Health Information Form

Accounting Of Certain Disclosures Request Form

Request To Restrict Uses Or Disclosures Of Protected Health Information Form

Complaint About Privacy Rights Form

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Request ID Card

Supplies

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New York State Health Care Reform Act, Public Goods Pool

HIPAA Transaction

PPOs

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Obtain Eligibility or Claim Status

W-9 Form

Pre-Authorization Requirement

ADA Claim Form for ACS Dental

Important Note for Dental Providers

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FSA, HRA or HSA Login

Forms