181. Form PEEHIP FPL 2G Federal Poverty Level Assistance Application - Alabama
INSTRUCTIONS: ALABAMA FEDERAL POVERTY LEVEL ASSISTANCE APPLICATION (FDL) AND CHILDREN'S HEALTH INSURANCE PROGRAM APPLICATION (CHIP) (Form PEEHIP FPL & CHIP) To apply for federal poverty level assistance or the st ...
183. Form CL-91 Request for Reimbursement Preferred Dependent Care Account - Alabama
INSTRUCTIONS: ALABAMA REQUEST FOR REIMBURSEMENT PREFERRED DEPENDENT CARE ACCOUNT (Form CL-91) To receive reimbursement for child day care, adult day care, before & after school care or other eligible dependent care a ...
184. Form CL-472 Request for Reimbursement Preferred Health FSA/HRA - Alabama
INSTRUCTIONS: ALABAMA REQUEST FOR REIMBURSEMENT PREFERRED HEALTH FSA/HRA (Form CL-472) In Alabama, state employees enrolled with BlueCross BlueShield use a form CL-472 to request a reimbursement for eligible health servi ...
185. Form ACT-18 Direct Deposit Authorization Agreement - Alabama
INSTRUCTIONS: ALABAMA DIRECT DEPOSIT AUTHORIZATION AGREEMENT (Form ACT-18) Alabama public employees enrolled in health insurance through BlueCross BlueShield use a form ACT-18 to authorize direct deposits of credits from ...
186. Form PEEHIP FSA Change 21 Flexible Spending Account Status Change - Alabama
INSTRUCTIONS: ALABAMA FLEXIBLE SPENDING ACCOUNT STATUS CHANGE (Form PEEHIP FSA Change) To document a change in your status as an Alabama public employee enrolled in a flexible spending account administered by BlueCross B ...
187. Form PEEHIP FSA Enroll 2H Flexible Spending Account Enrollment Application - Alabama
INSTRUCTIONS: ALABAMA FLEXIBLE SPENDING ACCOUNT ENROLLMENT APPLICATION (Form PEEHIP FSA) To enroll in an Alabama flexible spending account administered by the public education employer's health insurance plan, file a ...
188. Form CL-438 Medical Expense Claim - Alabama
INSTRUCTIONS: ALABAMA MEDICAL EXPENSE CLAIM (Form CL-438) Alabama public employees enrolled in a program administered by BlueCross BlueShield use form CL-348 to file a medical expense claim. This document can be obtained ...
189. MedImpact Medication Request Form - Alabama
INSTRUCTIONS: ALABAMA MEDICATION REQUEST FORM (MRF) Participating physicians and providers treating an Alabama public employee and obtaining coverage for a Prior Authorization drug for which there is no available suitabl ...
190. Form 10_2011 MedImpact Prescription Drug Claim Form - Alabama
INSTRUCTIONS: ALABAMA PRESCRIPTION DRUG CLAIM FORM (Form 10_2011) To process claims for prescription drugs for Alabama public employees enrolled in coverage administered by Medimpact, use the claim form discussed in this ...