The Joint Health Management Board (JHMB) seeks to make it easier for participants in the District’s health plan to have quick access to important forms related to our benefit offerings. Simply download the form you need, complete it, and return it to the appropriate vendor/office noted on the form.
FUSD – Life Event Change Form (PDF)
FUSD – Retiree Address Change Form (PDF)
Delta Dental – Claim Form (PDF)
Delta Health Systems – Accident/Illness Questionnaire (DOC)
Delta Health Systems – Coordination of Benefits Letter (DOC)
Delta Health Systems – Designation of Authorized Representative (DOC)
Delta Health Systems – Medical Claim Form (PDF)
Kaiser Permanente – Emergency Claim Form (PDF)
Kaiser Permanente – HIPAA Release Form (PDF)
Standard Life Insurance – Beneficiary Designation Form (PDF)
Standard Life Insurance – Group Life Certificate (PDF)
Standard Life Insurance – Portability Insurance Application (PDF)
Elixir – Member Self-Pay Reimbursement Form (PDF)
Elixir – Mail Order Form (PDF)