*Most employers and other organizations let you submit your claims online, or they give you personalized forms that help speed up the process. Use this medical form to submit an LTD claim. Use this medical form to submit a short-term disability claim.Īttending Physician’s Statement – LTD (General) (045-1355-GEN / 045-1356-GEN) Use these forms to report an absence under salary continuance services.Īttending Physician Statement – disability claim (020-3485-STD-LTD) Use these forms when you want to submit an STD claim. Short-term disability (STD) – plan member package
Use these forms when you want to submit an LTD claim. Long-term disability (LTD) – plan member package
Use this form when you want to submit medical expenses and services claims under your health spending account. Use this form when you want to submit medical expenses and services claims under your regular extended health-care coverageĮxtended health care – health spending account claim form (EHC-HSA-E) Extended health careĮxtended health care – standard claim form (EHC-E) Use this form when you want to submit a dental claim under your health spending account. Use this form when you want to submit a dental claim under your regular dental coverage.ĭental claim – health spending account claim form (DENT-HSA-E) If so, you can find the most popular non-personalized group claims forms here.* Dentalĭental claim – standard claim form (DENT-E) Your employer or organization may not have personalized claims forms.
