Blue Priority Flex: Employer Forms

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Employer Forms

• Premium Only Plan Employer Application (M-53216 12/06)
• Reimbursement Account Flexible Benefits Employer Application (H-8305 1/08)
• Reimbursement Account Flexible Benefits Employer Application including Flex Debit Card (H-8381 11/07)
• Health Reimbursement Account (HRA) Employer Application (H-8364 12/06)
• Health Reimbursement Account Employer Application including Flex Debit Card (H-8383 3/08)
  

Employee Forms

Member Education Materials
Order Blue Priority Flex member education materials on the Employer Toolkit.

Enrollment Forms

• Pre-Tax Premium Payments Mandatory Enrollment Form (H-8707 11/06)
• Pre-Tax Premium Payments Non-Mandatory (H-8711 11/06)
• Employee Reimbursement Account & Pre-Tax Premium Payment Mandatory Combination (H-8754 8/07)
• Employee Reimbursement Account & Pre-Tax Premium Payment Mandatory with Debit Card Authorization (H-8772 1/08)
• Employee Reimbursement Account & Pre-Tax Premium Payment Non-Mandatory Combination (H-8757 8/07)
• Employee Reimbursement Account & Pre-Tax Premium Payment Non-Mandatory with Debit Card Authorization (H-8774 4/08)
• Pre-Tax Premium Payments and Employee Reimbursement Accounts Change Form (H-8764 1/08)
• Health Reimbursement Account with Debit Card Authorization (H-8382 3/08)

Authorization Forms

• Automatic Reimbursement Authorization Form (H-8340 4/08)
• Direct Deposit Authorization Form (G-8704 11/06)

Reimbursement Forms

• 2007 Medical Travel Expense Form (H-8404 3/07)
• Flexible Benefits Request for Reimbursement (H-8303 06/07)
• Medical Necessity Form (H-8401 11/06)
• Orthodontic Payment Form (H-8402 12/06)

Enrollment Guides

• Premium-Only Plan Enrollment Guide (H-8110 12/06)
• Blue Priority Flex Enrollment Guide (H-8129 4/08): Without flex debit card, with enrollment form
• Blue Priority Flex Enrollment Guide (H-8130 4/08): With flex debit card, with enrollment form
• Blue Priority Flex Enrollment Guide (H-8131 4/08): With flex debit card, without enrollment form
• Blue Priority Flex Enrollment Guide (H-8132 4/08): Without flex debit card, without enrollment form
  

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