The Retirement Systems of Alabama

- Retirement / DROP
- Social Security
- ERS Members
- TRS Members
- RSA
- ERS
- TRS
- PEEHIP
- RSA-1
- JRF

Public Employees' Health Insurance Plan (PEEHIP)

PEEHIP Publications & Forms

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Publications
Open Enrollment Packet 2009 - 2010- deadline August 31, 2009, effective October 1, 2009
Member Handbook- effective October 1, 2008
Retirees with Medicare
PEEHIP Quarterly Newsletter
Hospital Medical Plan Summary of Benefits - effective October 1, 2006
PEEHIP Hospital Medical Matrix of Benefits- Group #14000 - - effective October 1, 2009
CHIP Summary of Benefits- Group #81000 - effective October 1, 2009
Supplemental Coverage Plan- Group #61000 - effective October 1, 2009
Health Care Flexible Spending Account Brochure - 2009
Dependent Care Flexible Spending Account Brochure - 2009

Forms
Health Insurance Forms
Flexible Spending Accounts Forms
Other PEEHIP Forms

Health Insurance Forms		back to top
	Health Insurance and Optional Enrollment Application
	Health Insurance and Optional Status Change
	Address Change Notification
	Southland National Vision Claim Form
	Southland National Dental Claim Form
	Southland National Indemnity and Cancer Claim Form
	Express Scripts Manual Claim Form
	Express Scripts Prior Authorization Request Form
	Hospital Medical Claim Form - Group # 61000 and #14000


Flexible Spending Accounts Forms		back to top
	Flexible Spending Accounts Enrollment Application
	Flexible Spending Accounts Status Change
	Address Change Notification
	Flexible Spending Accounts Direct Deposit Form
	Request for Reimbursement Form for Flexible Health Care Account
	Request for Reimbursement Form for Flexible Dependent Care Account
	Common OTC Meds Eligible for Your Health Care Spending Account


Other PEEHIP Forms		back to top
	Address Change Notification
	FPL and CHIP Application
	Retiree Employment Verification
	Refund Request

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