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. For 2024 claim forms, contact the health and welfare plans directly.

Medical

• Cigna Medical Claim Form
• Cigna International Claim Form
• Aetna Medical Claim Form
• Surest Medical Claim Form

Prescription Drugs

• Express Scripts Claim Form

Dental

• MetLife Dental Claim Form
• Delta Dental Claim Form
• HealthEquity Orthodontia Claim Form

Vision

• VSP Out-of-Network Reimbursement Form

Flexible Spending Accounts

• Health Care FSA Claim Form
• Dependent Day Care FSA Claim Form
• HealthEquity HSA Claim Form

Transition of Care

• Cigna Transition of Care Form
• Aetna Transition of Care Form
• Surest Transition of Care Form