Benefits Forms Health Benefits Medical Type Name Blue Shield Prescription Order Blue Shield Prescription Order – FAX Bronze Plan Enrollment Form Declination Agreement for Essential Health Plan Coverage Dependent Medical Plan Social Security Number Collection Form Disabled Dependent Certification Medical Plan Enrollment/Change Opt-Out/Waiver Election Agreement for Medical and/or Dental Premium Deduction Election PPACA Marketplace Notice Dental Type Name Delta Dental Claim Form (DPPO) – Out of Network Delta Dental Claim Form (DHMO) – Out of Network Dental Plan Enrollment/Change Disabled Dependent Certification Opt-Out/Waiver Election Agreement for Medical and/or Dental Premium Deduction Election Vision Type Name Disabled Dependent Certification Premium Deduction Election Vision Out-of-Network Claim Vision Plan Enrollment/Change – Eligible Units Cobra Type Name COBRA Medical Plan Enrollment/Change COBRA Dental Plan Enrollment/Change COBRA Vision Plan Enrollment/Change Life Insurance Type Name Life Insurance and AD&D Enrollment Securian Life Insurance (County Sponsored)
