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Frequently Used Forms & 
Additional Resources

Additional Resources and Forms

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  • 2023 Aetna Summary of Benefits & Coverage (SBC) Medical Plan Broad Network

  • Aetna Broad Network Summary Plan Description

  • Aetna - Broad Network Benefits Summary

  • Aetna Plan Broad Network Schedule of Benefits

  • Mobile App Instructions*

  • Aetna Concierge Program

  • Preventive Care Flyer

  • Aetna Machine-Readable File

SimplePay Resources

  • SimplePay (Meritain) Machine-Readable File

  • SimplePay Authorization Form – After completing your enrollment, SimplePay does require an authorization form to enroll in plan.

  • Need help navigating your account? This 20 min Webinar (password to access the link: Simple2021!)  will go over:

    • Registering/Activating your account

    • Navigating the portal at a high level

    • How to search for a provider

    • How to search for a pharmacy and prescription costs

    • Accessing SimplePay claims and statements

    • How to access ID cards

  • Mobile App:

  •  SimplePay Health Member Portal

2023 SimplePay Summary of Benefits & Coverage (SBC) Medical Plan Broad Network

2023 SimplePay Summary Plan Description

Medical Resources

  • Womans Preventive Care Flyer

  • RX Home Delivery Flyer & Form

  • Extra Care Health Card

  • Formulary Drug List Instructions

  • Medical Claim Form

  • Personal Health Information (PHI) Release Form

Benefit Notices

  • Notice of Privacy Rights

  • Welfare Benefit Plan - Summary of Annual Report

  • Medicare Part D Notice

  • Womans Health & Cancer Rights Act Notice

  • Newborns & Mothers Health Protection Act Notice

  • Chip Notice

  • Health Insurance Exchange Notice

  • Special HIPPA Notice

  • Surprise Billing Model Notice

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Health Savings Account

  • Benefit Summaries

  • Optum Bank Qualified Medical Expenses

  • Optum Bank HSA User Guides

  • Optum Bank Rollover Information

  • Optum Bank Planning Guide For Ages 50+

  • How to access IRS tax forms for you H.S.A.

Forms​

  • Optum Bank Consent Form

  • HSA Deduction Change Process

  • Optum Bank Rollover Transfer Form

  • Optum Bank Withdrawal/Distribution Form

  • Digitally Sign the Optum Consent Form

Flexible Spending Accounts

  • Navigating your account:

  • Qualified Expenses * Make sure to select the appropriate FSA

  •     Account (Dependent Care, Health Care, Limited Purpose)*

  • Video: How to file a claim with Optum via desktop or app

  • Video: How to upload a Receipt

  • FSA Medical Reimbursement Form

  • FSA Dependent Care Reimbursement Form

Optum Bank
Health
Ameritas
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Dental Plan

  • Ameritas Dental Benefit Summary

  • Ameritas Account Login Guide

  • Ameritas Dental Plan Summary Description

  • Ameritas Privacy Notice

  • Dental & Vision - Summary Annual Report

Vision Plan

  • Vision Benefit Summary

  • Vision Benefits Guide

  • Ameritas Vision Plan Summary Description

  • Vision Claim Form

Reliance & Matrix

Disability and Leave of Absence

Life Benefits

  • Support Guide for Short Term Disability and/or Leave of Absence

  • How to File a Leave of Absence Claim

  • Missed Deduction Options

  • Parental Leave Notice

  • Life & Disability - Annual Report

  • Supplemental Life Insurance Rate Sheet

  • Life Insurance EOI Form

  • Life & Disability - Annual Report

  • Group Life Policy

Voluntary Coverages

  • Group Accident Coverage

  • Group Cancer (Grandfathered Plan)

  • Group Critical Illness Coverage

  • Group Universal Life Coverage

  • Wellness Claim Form

  • Cancer Claim Form

  • Accident Outpatient Physician's Treatment Claim Form

  • Accident Claim Form

  • Critical Illness Claim Form

  • Claim Direct Deposit Authorization

  • EOI Health Statement Form

Principal

Retirement

  • Navigating your account:

  • Qualified Expenses * Make sure to select the appropriate FSA

  •     Account (Dependent Care, Health Care, Limited Purpose)*

  • Video: How to file a claim with Optum via desktop or app

  • Video: How to upload a Receipt

  • FSA Medical Reimbursement Form

  • FSA Dependent Care Reimbursement Form

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