Forms

PEEHIP provides the most common forms needed during your career and retirement online.

For greater convenience, many of the functions achieved by the forms below can be done instantly online via our Member Online Services (MOS) website. You may also request these forms from Member Services.

• Health Insurance
• Claim Forms
• Flexible Spending Accounts
• Other PEEHIP Forms

Health Insurance Forms

• New Enrollment and Status Change
• Premium Assistance Application (PAA)

Claims Forms

• Southland Benefit Solutions Vision Claim Form
• Southland Benefit Solutions Dental Claim Form
• Southland Benefit Solutions Indemnity and Cancer Claim Form
• Express Scripts Prescription Drug Reimbursement Form
• Hospital Medical Claim Form - Group #14000 and #61000

Flexible Spending Accounts Forms

• Flexible Spending Accounts Enrollment Application
• Flexible Spending Accounts Status Change
• Flexible Spending Accounts Direct Deposit Form
• Healthcare Flexible Spending Account Reimbursement Form HealthEquity
• Dependent Care Reimbursement Account Reimbursement Form HealthEquity
• Orthodontia Reimbursement Form

Other PEEHIP Forms

• Healthcare Provider Screening Form - take to your doctor
• Pharmacy Biometric Screening Form - take to your pharmacy
• Address Change Notification
• Coordination of Benefits (COB)
• Retiree Employment Verification (REV)
• Commitment to Participate in Tobacco Cessation
• PEEHIP HIPAA Privacy Authorization
• Dependent Eligibility Verification Required Documentation