Forms
 

Forms

Before choosing a claim form, please check with your employer to see if UMR administers that benefit plan. This will ensure your form is submitted to the appropriate contact for claims processing.

Medical Claim Form (HCFA1500)

Medical Claim Form (EZ Claim)

Dental Claim Form

Health Care Flex Claim Form in data enterable MS Word Form Format

Health Care Flex Claim Form in PDF format for completion after printing

Dependent Care Flex Claim Form in data enterable MS Word Form Format

Dependent Care Flex Claim Form in PDF format for completion after printing

Eligible/Ineligible Flex Expense Lists

Privacy Forms—including the Patient Rights Authorized Rep Form

Request for Notification

 

 

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