Downloadable Form for 51–150 Employees
| Prescription Drug Forms | |||
|---|---|---|---|
|
Form Name
|
Form Number
|
Date
|
|
Affidavit of Domestic Partnership  |
#20551 |
01/05 |
|
| Statement of Termination of Domestic Partnership |
#20560 |
02/07 |
|
| Tax Information on Health Benefits for Domestic Partnership |
#20559 |
02/07 |
|
| General Notice of Special Enrollment Rights |
#22963 |
04/15 |
|
| Prime Prescription Drug Claim Form |
#3272-IL
|
01/16 |
|
| PrimeMail Prescription Order Form |
#WI0316
|
07/17 |
|
| Privacy Practices Notice and HIPAA Privacy Forms |
N/A |
11/16 |
|
