Claim Forms

Claim Forms

Please note that the forms below are provided for the benefit of employees and their families who are enrolled in the Firm-provided health and welfare plans named below.

Medical

• UnitedHealthcare Medical Claim Form
• Cigna Medical Claim Form
• Cigna International Claim Form

Prescription Drugs

• Prescription Drug Claim Form – OptumRx
• New Prescription Mail-In Form – OptumRx

Dental

• MetLife Dental Claim Form
• Delta Dental Claim Form

Vision

• VSP Out-of-Network Reimbursement Form

Flexible Spending Accounts

• Health Care FSA Claim Form
• Limited Purpose FSA Claim Form (Option C Dental and Vision Expenses Only)
• Dependent Day Care FSA Claim Form

Transition of Care

• UnitedHealthcare Transition of Care Form
• Cigna Transition of Care Form
• Cigna Transition of Care – Mental Health

Provider Nomination

• Cigna – Provider Nomination Form