Human Resources

Medical Forms & Resources

Request replacement medical/dental cards (only)

To replace any of your medical or dental cards, please call 888-276-4732
Please verify what address they have on file. If it is different than your current address, you will need to contact Tamara Terry at (509) 242-0478 to request your cards.

Change Request Forms

Employee Benefit Information Change Request Form
Employee Benefit Termination Request Form

Reimbursement Forms
Claims Reimbursement Request Form

BlueCard PPO Out-of-Network Reimbursement Form

Medco RX Mail Order Form

Express Scripts Rx Reimbursement Form

United Concordia Dental Claim Form

United Concordia Dental Claim Form-Instructions
Applicant/Eligibility Forms

Employee Health Care Enrollment Application
HIPAA Consent for Release
Medical Plan Verification 2014
Pretax Benefit Election 2014
Medical Costs

Health Care Assistance Plan (HCAP) Documents

This Plan document describes the provisions of the Health Care Assistance Plan for employees of the Seventh-day Adventist Organizations of the North American Division working in the United States (“Plan”). Please refer to the North American Division Working Policy Y 22 for the supporting general philosophy of this Plan.

2014 Health Care Assistance Plan (HCAP) Document
2014 Summary of Benefits and Coverage (SBC)
2014 Health Care Assistance Plan (HCAP) Changes

Aflac Click Here for Info

New Health Insurance Marketplace Coverage Options and Your Health Coverage

FMLA Click Here for Info

International Insurance Click Here for Options