Form #

Title

File Type

H0_F098

HIPAA Authorization Information Release Form

1-93329
(1-02)

Retiree Health Care Enrollment / Change Form
To change your coverage - if HMOs are available in your ZIP code - from one HMO to another, from an HMO to the managed care network, or from the managed care network to an HMO

1-19673

Blue Cross Health Care Claim Form
To file a medical claim if you are covered by this plan.

1-19674

Caremark Prescription Drug Mail Order Form
To fill maintenance prescriptions by mail if you have Caremark prescription drug coverage.

Direct Deposit Form - Electronic Funds Transfer Form
To have your monthly pension benefit deposited electronically in your bank, or to change the bank where your check is deposited electronically.

H0-F065

Beneficiary Designation Life/Accident Insurance
To add or drop a beneficiary.

H0-F069

Disabled Dependent Certification

H0-F082

Student Status Verification

H0-F083

Aetna US HealthCare Medical Benefits Request
To file a medical claim if you are covered by this managed care network.

H0-F084

Retiree Information Card
Use this card to change your address or to request the following forms:

• Change Income Tax Withholding Amount
• Change Direct Deposit for Connecticut General
• Convert Company-Sponsored Life Insurance to Personal Policy
• Reduce Amount of Your Life/Accident Insurance Coverage

H0-F085

Unicare Claim Form
To file a medical claim if you are covered by this plan.