Forms and Documents

Change Your Address

Change of Address Form (English)
Change of Address Form (Spanish)

Enrollment Forms

Full-Time Health Benefits

Enrollment Form for Full-Time Health Benefits Plan Employees (English)
Enrollment Form for Full-Time Health Benefits Plan Empolyees (Spanish)
Kaiser HMO Enrollment Form
Olam Enrollment Form for Full-Time Health Benefits Plan Employees (English)
Olam Enrollment Form for Full-Time Health Benefits Plan Employees (Spanish)

Seasonal Medical Benefits

Enrollment Form for Seasonal Medical Benefits (English)
Enrollment Form for Seasonal Medical Benefits (Spanish)
Olam Seasonal Medical Benefits Enrollment Form (English)
Olam Seasonal Medical Benefits Enrollment Form (Spanish)

Seasonal Benefits

Enrollment Form for Seasonal Benefits (English)
Enrollment Form for Seasonal Benefits (Spanish)

Summary Plan Description (SPD)

Medical

Full-Time Health Benefits
(annual minimum work hours required)

Full-Time Health Benefits Plan Summary of Benefits and Coverage
Full-Time Health Benefits Plan Kaiser HMO Summary of Benefits and Coverage
Full-Time Health Benefits Plan Medical and Prescription Drug Benefits Comparison Chart

Seasonal Medical Benefits
(pre 7/1/2003 three-year seniority)

Seasonal Medical Benefits Plan Summary of Benefits and Coverage
Seasonal Medical Benefits Plan Medical and Prescription Drug Benefits Comparsion Chart

Hip and Knee Hospitals / Mammogram Providers

Hip and Knee Hospitals
Mammogram Network

Dental

ARRIN Participating Dentists
Dental Allowance Schedule
Dental Claim Form

Vision

Full-Time Health Benefits
(annual minimum work hours required)

Vision Benefit Summary – 1400 Hour Participants (English)
Vision Benefit Summary – 1400 Hour Participants (Spanish)

Seasonal Medical Benefits
(pre 7/1/2003 three-year seniority)

Vision Benefit Summary – Non-1400 Hour Participants (English)
Vision Benefit Summary – Non-1400 Hour Participants (Spanish)

Seasonal Benefits

Vision Benefit Summary – New Entrants (English)
Vision Benefit Summary – New Entrants (Spanish)

Additional Documents

Authorization to Use and/or Disclose Personal Health Plan Information (English)
Authorization to Use and/or Disclose Personal Health Plan Information (Spanish)
Notice of Privacy Practices (English)
Notice of Privacy Practices (Spanish)
Surprise Billing Notice (English)
Surprise Billing Notice (Spanish)
Women’s Health and Cancer Rights Act Notice (English)
Women’s Health and Cancer Rights Act Notice (Spanish)

Claims Forms

Dependent Dual Coverage Questionnaire (English)
Dependent Dual Coverage Questionnaire (Spanish)
Employee Dual Coverage Questionnaire (English)
Employee Dual Coverage Questionnaire (Spanish)
Third-Party Liability Packet (English)
Third-Party Liability Packet (Spanish)