DMBA Forms Library

General Enrollment Forms

• Employee Benefit Enrollment Form
• Retiree Benefit Enrollment Form
• DMBA-affiliated HMO Applications
• Senior Dental Plan Enrollment Form
• Automatic Premium Debit Authorization Agreement
• Disability Direct Deposit Authorization
• Declaration of Insurability
• Authorization to Disclose Retirement or Life and Accident Benefit Information
• Authorization to Use and/or Disclose Protected Health Information (PHI)

DMBA Medical, Dental, and Prescription Forms

• Medical and Dental Claim Form
• International Medical and Dental Claim Form (for reimbursement of services received outside the U.S.)
• Navitus Prescription Drug Claim Form
• Navitus Foreign Prescription Drug Claim Form
• Member Appeal Form
• Member Benefit Suggestion Form
• Provider Nomination Form
• Provider Review Form
• Claim Information Request (for accident, injury, or illness)
• Home Sleep Study Physician FAX Order
• Home Sleep Testing History and Physical Questionnaire

COBRA Forms

• COBRA Election Form
• Notice of Qualifying Event
• Notice of Second Qualifying Event
• Notice of Disability
• Notice of Cessation of Disability
• Notice of Other Coverage or Medicare Entitlement

Medicare-related Forms

• Medicare Part B Claim Form

Flexible Spending Account (FSA) Forms

• Flexible Spending Claim Form for Healthcare Expenses
  (can be filled out online before printing)
• Flexible Spending Claim Form Dependent Care Expenses
  (can be filled out online before printing)
• Flexible Spending Enrollment
  (can be filled out online before printing)
• Flexible Spending Letter of Medical Necessity
  (can be filled out online before printing)
• Flexible Spending Direct Deposit Authorization

Health Savings Account (HSA) Forms

• Authorization to Disclose Health Savings Account (HSA) Information

Life Benefit Forms

• Beneficiary Form   Review and designate your beneficiaries online right now.
• Supplemental Group Term Life Application
• 24-Hour Accidental Death & Dismemberment Application
• Retiree Supplemental Group Term Life Application
• Retiree Supplemental Group Term Life Application (hired on or after April 1, 2010)

Financial Benefits Forms

• Beneficiary Form   Review and designate your beneficiaries online right now.
• Authorization to Disclose Retirement or Life and Accident Benefit Information

Deseret 401(k) Forms

Click here to access Deseret 401(k) Plan forms on Empower Retirement’s website.

• Form W-4P federal withholding form (Savings)