Group Health Plan

Forms

• Health Insurance Application or Change (SFN-60036)
• Physician's Form for Handicapped Dependent (SFN-58798)
• Application for Dependent Disability (SFN-58856)
• Authorization for Use or Disclosure of Protected Health Information (SFN-58769)
• Health Care Information Release Accounting Form (56768)
• Participant's Authorization to Disclose Protected Health Information (SFN-58770)
• Request to Access Protected Health Information (SFN-58771)
• Participant Request for Confidential Communications (SFN-58772)
• Request for Restrictions On Use and/or Disclosure of Protected Health Information (SFN-58773)
• Notice of Change - Member Data Record (SFN 10766)
• Continuation of Group Insurance Coverage (COBRA) (SFN-14120)