Human Resources Forms

All of our forms are in PDF format, so you will need to download and install Adobe Acrobat® if you have not already done so.

2010 Open Enrollment Material

Frequently Asked Questions - PDF
Medical Benefit Summary - 2009 and 2010 Side by Side - PDF
HIPAA Release Form - PDF
2010 Open Enrollment form - PDF
2010 Open Enrollment form (AFSCME) - PDF
Rx4 Drug List Effective January 1, 2010 - PDF

How to access this list on the MyHumana Web site - PDF

Humana 2010 Drug List Changes

Prior Authorization - PDF
Quantity Limits - PDF

Clermont County Life Insurance Enrollment Form - PDF
A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form - PDF
2010 Voluntary Life and AD and D Insurance Rates - PDF
Chard Snyder Flexible Spending Account Brochure - PDF
Chard Snyder Enrollment Form - PDF
DentalCarePlus - 2010 Summary Sheet - PDF
EyeMed Outline 2010 - PDF
MyHumana Flyer - PDF
MyHumana Quick Start Guide - PDF
Humana RightSource - PDF
Humana RightSource Order Form - PDF
Humana Health Assessment - PDF
Humana ER or Urgent Care - PDF

Claim Forms

Rx Mail Order Form - 247 KB PDF
CIGNA - Accelerated Benefits Claim Form - 110 KB PDF
CIGNA - Dismemberment Claim Form - 115 KB PDF
CIGNA - Life Insurance - How to file Life, Accident or Waiver claim - 31 KB PDF
CIGNA - Life Insurance - Accident Claim Form - 162 KB PDF
CIGNA - LTD Claim Form - 196 KB PDF
CIGNA - Waiver of Premium Claim Form - 40 KB PDF
EyeMed Out of Network Claim Form - 77 KB PDF
FSA Reimbursement Request Form - 72 KB PDF
FSA Debit Card Substantiation Form - 93 KB PDF
Medical Claim Form - 49 KB PDF

Benefit Plan Information

Employee Benefits Handbook - 483 KB PDF
Employee Benefits Handbook - DJFS - AFSCME Members - 426 KB PDF
Medical – 2008 Humana Summary Plan Description For the NPOS 1 Plan - 478 KB PDF
Medical – 2008 Humana Summary Plan Description For the NPOS 2 Plan - 478 KB PDF
Flexible Spending Account (FSA) Information - 342 KB PDF
NPOS 1 2009 Outline - 87 KB PDF
NPOS 2 2009 Outline - 84 KB
DentalCare Plus Summary Sheet - 60 KB PDF
EyeMed Plan Outline - 856 KB PDF
What is CONCERN Services? - 457 KB PDF
HIPAA Privacy Notice - 71 KB PDF
HIPAA Release - 112 KB PDF

Benefit Election Forms

2009 - General Population - 513 KB PDF
2009 - AFSCME - 510 KB PDF
2009 - FOP - 507 KB PDF
2009 Voluntary Life Rates - 110 KB PDF
Clermont County Life Enrollment Form - 20 KB PDF
Chard Snyder S125 Flexible Benefit Enrollment Form - 65 KB PDF
CIGNA Beneficiary Change Form - 124 KB PDF
Flexible Spending Account - Qualifying Event Change Form - 53 KB PDF

COBRA Information

Initial COBRA Notification Document - 96 KB PDF
The Basics of COBRA - 54 KB PDF
COBRA – Employer Notification Form - 76 KB PDF
COBRA Information - 193 KB PDF

Miscellaneous

CIGNA - Life Insurance Conversion Form - 340 KB PDF
CIGNA - Life Insurance Portability Form - 639 KB PDF
Accident Conversion Form - 59 KB PDF
LTD Conversion Claim Form - 127 KB PDF
Waiver of Premium Claim Form - 40 KB PDF
Group Long Term Disability - Conversion - 127 KB PDF
Important Numbers and Web Sites - 59 KB PDF
Guide To An EOB - 439 KB PDF