Forms for Self-Funded Plans
Primary Plan Enrollment
Add Dependent
Termination, Address Change
Medical Claim
Dental Claim
Vision Claim
Student Certification
Accident Questionnaire
Forms for Health Reimbursement Arrangements (HRAs)
HRA Plan Enrollment
Termination, Address Change
HRA Add Dependent
HRA Claim Form
HRA Claims Filing Handout
Medical Necessity
Health Reform Expense Types
Forms For Flexible Spending Accounts (FSAs)
All Three Option Election Form
Two Option Election Form
Premium Only Election Form
FSA Add Dependent Only
Termination, Address Change
FSA Claim Form
FSA Medical Planning Form
FSA Eligible & Ineligible Services
FSA Over-The Counter Drugs
FSA Rules & Coverage Information
Medical Necessity
Health Reform Expense Types
Dependent Care Claim Form
COBRA Forms
COBRA law requires that each COBRA eligible Plan have procedures to administer the COBRA requirement. This section provides procedures and forms to allow clients and Plan Participants to have access to this information to help manage their COBRA needs.

Initial Notice of COBRA Rights
COBRA Denial Notice
Notice of COBRA Qualifying Event
Notice of Second Qualifying
Event Notice of COBRA Disqualification Event
Notice of Disability
HIPAA Privacy Rule Sample Forms
Business Associate Agreement
Authorization For Release of PHI, General Use
Authorization For Release Of PHI, Medical Plan Use
Plan Notice of Privacy Practices
Privacy Plan Amendment

Home   |   About Us   |   Our Services   |   Our Partners   |   Plan Forms   |   Useful Information   |   Participant Login   |   Provider Login   |   Privacy   |   Legal
© Copyright 2014 Avalon Benefit Services, Inc. All rights reserved.
No reproduction of any images or content without written consent.
6543 Commerce Parkway, Suite M, Dublin, OH 43017
Phone: 800-820-4516    Fax: 614-793-9733