FORMS

Make sure to submit any 2014 claims in time to have them processed.

You have 180 days to to file a claim, starting from the date that the service was rendered. Please submit any unprocessed claims ASAP for reimbursement. If your claim has already been processed and you do not agree with the plan’s benefit determination, submit your grievance within 180 days of the EOB (Explanation of Benefits).

Need a form? If you stay in-network, your provider will submit claims for you. When you visit out-of-network providers, you will need to submit a paper claim. Select the form you'd like to download. You can then review, print, or save the document.

  • Claim Form: Use this form if you need to submit a paper claim for medical services.

  • International Claims Form: Use this form if you have to receive medical care while traveling abroad. You will need to pay out-of-pocket for any services received and use this form to file a claim for reimbursement.

  • Gym Reimbursement Form for FIC Metal Plan Members Only: Use this form to receive a partial reimbursement for gym membership fees. Please note this only applies to FIC metal plan members.

To view and print PDF (Portable Document Format) files, you can use Adobe Reader, which is available free from the Adobe website. To visit the site, click here.