Benefits Fund Forms

Form Name (click or tap to view)	Description	(click or tap to download)
ESI Prescription Drug Reimbursement Form	Reimbursement for Prescription Drugs
Oxford Sweat Equity Program	Reimbursement for health club/gym membership
ESI Home Delivery Order Form	Rx mail-order forms for maintenance meds
Aetna Claim Form	Dental care Claim Form
Davis Claim Form	Vision Care form
Oxford Claim Form	Medical claim form
PHI Authorization	Authorization form for the Disclosure of personal health information
Physician Nomination	Recommend a physician to join Oxford Network

Form Name (click or tap to view)	Description	(click or tap to download)
Hartford Short-term Disability Continued	Attending physician’s statement of continued disability
Hartford Short-term Claim	Notice and proof of claim for short-term disability benefits
Hartford Authorization	Authorization form for the disclosure of personal health information
Hartford Long-term Claim	Long-term disability claim statement
Hartford Accident Details	Your disability may have been caused by an insured person who would have been liable to pay damages.
Hartford Mental Heath Statement	Attending physician’s statement of continued disability for mental health
MetLife Attending Physician Statement	Attending physician’s statement of continued disability
MetLife Short-term Claim	Notice and proof of claim for short-term disability benefits
MetLife Authorization	Authorization form for the disclosure of personal health information
MetLife EFT Authorization	Authorization of direct deposit of disability payment
MetLife Psychiatric Questionnaire	Attending physician’s statement of continued disability for mental health

Form Name (click or tap to view)	Description	(click or tap to download)
Young Adult Form	Dependents ages 26 through 29 are eligible for medical insurance only
Enrollment Form	Used to enroll in the Benefits Fund