HIPAA Authorization – Private Health Information (PHI)

• HIPAA Authorization – Private Health Information (PHI)
  

Life Insurance

• Life Insurance Beneficiary Form
• Life Insurance Certificate of Coverage

Kaiser Medical

• 2024 07 – 2025 06 Kaiser SBC
• 2024 07 – 2025 06 Evidence of Coverage (EOC)
  
  • Principal Benefits and Co-payments for Kaiser Permanente
  • 2024 Disclosure Part 1
  • 2024 Disclosure Part 2
  • Kaiser Digital Resources and Tools

Vision Service Plan

• Vision Service Plan
• Evidence of Coverage and Disclosure Form

Basic Dental

• Table of Allowances (Applicable for Dates of Service through March 31, 2023)

• Table of Allowances (Applicable for Dates of Service Effective April 1, 2023)

Major Medical and Basic Dental Plan

• Enrollment Form

United Concordia®

• Schedule of Benefits