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Enrollment Forms
** Change of Address
For changes of address and other important information, please complete the above form & return to Human Resources. If you have benefits, you will also need to complete the Bard-Rose & Kiernan, Inc Enrollment Application (below) & return to Janet Algiere to notify your benefit providers of your change of address.
Bard Benefit Enrollment form - Administration
Bard Benefit Enrollment form - B&G Union
Bard Benefit Enrollment form - Faculty
Bard Benefit Enrollment form - Security Union
Bard Benefit Enrollment form-Visiting & Graduate Faculty
Bard-Rose and Kiernan, Inc. Enrollment Application
COBRA General Notice
The signature page (page 4) is required.
Flexible Spending Account Enrollment 2009
Long-Term Care Insurance Election Form
Employee short form.
Qualified Transportation Expense Plan Enrollment 2009
Claim Forms
Blue View Vision Claim Form (Claims beginning 7/01/09)
BlueCard BCBS International Claim Form
Claim form for international medical claims
Davis Vision Claim Form (Claims through 6/30/09)
To Claim from non-DavisVision providers
Delta Dental Claim Form
Dependent Care Expenses Form
Please use the attached form form when filing dependent care flexible spending account claims.
If you have any questions, please contact Benefit Resources at 1800-473-9595
Empire BCBS HIPPA Authorization form
Empire Blue Cross/Blue Shield Claim form
Use to claim out-of-network expenses from Empire.
Express Scripts Prescription Drug Claim form
Use this form to claim reimbursement for out-of-pocket prescription drugs purchases.
Flexible Spending Claim form (Medical & Dependent Care)
For Medical and Dependent Care claims from your Flexible Spending Account. Please call Participant Services at 1(800) 473-9595 if you require further assistance, or go to benefitresource.com and log in for account information.
Mail Order Pharmacy Form
To order your prescriptions through mail order by Express Scripts.
QTE Transportation Claim form
Payroll Forms
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