Forms

ACH Request Form for Short Term Disability

Allocation of Reciprocal Contributions

Appeal Form

Change of Address Form

Consociate Portal Quick Start Guide

Disability Form

HIPAA Authorization

Optum Rx – Prescription Reimbursement Form

Opt-Out EOB Form

Personal Representative Form

Self-Contribution Reimbursement Form

VSP Out-Of-Network Reimbursement Form

Wellness Program Physician Form 2026