Forms
Claims
Dental Claim Form (PDF
File)
Medical/Vision Claim Form (PDF
File)
Prescription Drug Claim Form for
Major Medical Plans (PDF File) - plans
with pharmacy benefits administered under medical plan
Prescription Drug Claim Form
for Med Impact Plans (PDF File) -
plans with retail prescription drug benefit
Individual Enrollment/Changes
Medical & Dental
Enrollment (Online)
Medical & Dental Enrollment (PDF
File)
Group Enrollment/Changes (through employer)
Standard Option
- Dental Only Enrollment (PDF file)
- Medical Only Enrollment (PDF file)
- Medical and Dental Enrollment (PDF file)
- Affidavit of Domestic Partnership for qualified plans (PDF File)
- Declination of Dental Coverage (PDF file)
- Declination of Medical Coverage (PDF file)
Dual Option
- Dual Option Dental Only 5-99 (PDF file)
- Dual Option Medical Only 5-99 (PDF file)
- Medical and Dual Option Dental 5-99 (PDF file)
- Dual Option Medical and Dental (PDF file)
- Dual Option Medical and Dual Option Dental 5-99 (PDF file)
HIPAA/Privacy Forms
Authorize ODS to use/disclose information
about a member (PDF File) - Instructions
Authorize Provider or Hospital
to use/disclose information to ODS (PDF
File) - Instructions
Other Forms
Coordination
of Benefits Information (PDF File)
Grievance and Appeal Form (PDF
File)