Frequently Used Forms

Below you will find documents to help make the most of your health plan benefits.

Automatic Payment form (PDF) - Sign-up to have your plan premium automatically deducted from your checking or savings account each month.

Mammogram incentive certificate (PDF) - Get a mammogram and get an incentive reward. Applies to eligible members age 40 to 69.

Opt-in to Receive Non-Plan Information (online form) – Complete this form to receive updates about state or federal legislation, grassroots advocacy, community activities, and more.

Statement of Representative form (PDF) - Appoint a representative to act on your behalf.

UCan! Do-It-Yourself Kit (PDF) - Order a kit containing a set of portable exercise gear for just $10 (one additional kit can be purchased for $40).