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Forms/Resources

Click on the links below to access and download different forms:

Health Options Program Application/Change Form (PDF 666K) (If you accidentally select an option and cannot change your selection, simply close the tab and click this link again to open a new blank form.)

Health Options Program Major Medical Claim Form (PDF 683K)

Rx Reimbursement Form (PDF 121K)

Rx Prior Authorization Form

Mail Service Prescription Order Form (PDF 497K)

MetLife Dental Claim Form (PDF 675K)

CMS’ Appointment of Representative Form (Form CMS-1696) (PDF 67K)

Notice of Non-Discrimination and Language Assistance (PDF 237K) A notice describing PSERS' non-discrimination policies and information on where to get language translation assistance for reviewing Health Options Program materials.

 

 

 

 

 

 

 

 

 

 

Last modified August 29, 2017