Admin Forms List

• Change of Address Requisition

• Consent to Release Information

• Electronic Funds Transfer (EFT) Authorization for Claim Payments

• Over-Age Dependent Coverage Request Form

• Registration Change Form

• Retire Benefit Plan (60-64) Registration Form

• Request for Appeals Form IHFWC 2022

• Self-Payment Electronic Funds Transfer (EFT) Pre-Authorized Debit (PAD) Agreement

• Spousal Authorization Form

Claim Forms List

• Dental Claim Form

• Drug Claim Form

• Health Spending Account Claim Form

• Pre-Determination - Hospital Bed Assessment Form

• Pre-Determination - Knee Brace Assessment Form

• Pre-Determination - Nursing Care Assessment Form

• Pre-Determination - Oxygen Concentrator Assessment Form

• Pre-Determination - Wheelchair Assessment Form

• Supplementary Health Claim Form

• Travel Letter and Card 

• Vision Claim Form

• Travel Coverage Booklet

Disability/Freezing List