| Enrollment and Status Change Forms | Use these forms if your employer has requested you to submit any Enrollment or Participant Status Change forms. |
| Special Enrollment Verification Form | Use this form for special enrollment events. |
| Claim Forms | Use these forms if you need to submit a claim to ACS. |
| Forms to Provide Additional Information to Process Claims | Use these forms if additional information is required by ACS to process your claim(s). |
| Prescription Reimbursement Claim Forms | Use these forms to request reimbursement(s) from your pharmacy network. |
| Use this form only if your plan's dental benefits are through ACS. | |
| Use these forms if you need to give a Notice about COBRA to ACS. | |
| Use these forms if you want to give authority to someone else to receive information from ACS about your medical or dental claims. | |
| Use this form to request reimbursement for Medical, Vision or Prescription claims. | |
| Use this form to request reimbursement for Medical, Vision or Prescription claims. |
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You must have Adobe Acrobat Reader installed on your computer to view and/or print the forms on the web pages shown above. If you do not, you can download a free version from Adobe by clicking on this link below and choosing GET ACROBAT READER.  If you have any problems with the PDF forms, please visit our TROUBLESHOOTING PDF FILE page. To get a hard copy of the forms below, you must open the forms with Adobe Acrobat Reader and choose the FILE/PRINT option. |
[Updated 08/22/2006]