1571. Form 71-5411 Application for Special Bonus Game - Arizona
INSTRUCTIONS: ARIZONA APPLICATION FOR SPECIAL BONUS GAME (Form 71-5411) Arizona organizations wishing to organize a special bonus game when operating bingo games must submit a form 71-5411. This application can be obtained from the ...
1572. Refund Request - Alabama
INSTRUCTIONS: REFUND REQUEST Alabama public education employees who are enrolled in the Public Education Employees' Health Insurance Plan (PEEHIP) can request a refund from the program related to treatment by filing the form di ...
1573. FPL Application - Alabama
INSTRUCTIONS: FEDERAL POVERTY LEVEL ASSISTANCE APPLICATION (FPL) Alabama public employees who are active or retired members of the state-administered PEEHIP health insurance plan use the form discussed in this article in order to a ...
1574. Common OTC Meds Eligible for Your Health Care Spending Account - - Alabama
INSTRUCTIONS: COMMON OTC MEDS FOR ELIGIBLE HEALTH CARE FSA REIMBURSEMENT Alabama public employees enrolled in a Flexible Spending Account within the state-administered PEEHIP health insurance plan were eligible for coverage on cert ...
1575. Request for Reimbursement Form for Flexible Dependent Care Account - Alabama
INSTRUCTIONS: REQUEST FOR REIMBURSEMENT PREFERRED DEPENDENT CARE ACCOUNT Alabama public employees enrolled in the state PEEHIP program and who have a flexible account for dependent care can use the form discussed in this article to ...
1576. Request for Reimbursement Form for Flexible Health Care Account - Alabama
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 who wish to file a request fo ...
1577. Flexible Spending Accounts Direct Deposit Form - Alabama
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 this plan can use the form d ...
1578. Flexible Spending Accounts Status Change - Alabama
INSTRUCTIONS: FLEXIBLE SPENDING ACCOUNT STATUS CHANGE Alabama public employees who have enrolled in the flexible spending account program of the state's PEEHIP health insurance fund can use the form discussed in this article to ...
1579. Flexible Spending Accounts Enrollment Application - Alabama
INSTRUCTIONS: FLEXIBLE SPENDING ACCOUNT ENROLLMENT APPLICATION Alabama public employees who are active members of the state-administered PEEHIP health insurance plan can use the application discussed in this article to enroll ...
1580. Hospital Medical Claim Form - Group 61000 and 14000 - Alabama
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 to seek payment for services provided ...