Pharmacy Plan

PTRX

     New Prescription Mail Order Form

     Mail Order Registration Form


Claim Forms

     Cy-Fair ISD Open Access Plus (OAP) Plan and Network Plan Claim Form
     CIGNA HealthCare
     (This form is for the KelseyCare HMO plan, but only good for the Cy-Fair OAP Plan
      for services received on or before August 31, 2009)

     Cigna Choice Fund HRA Claim Form
     CIGNA HealthCare
     (This form is only for services received in the new CFISD Choice Fund HRA Plan
     on or after September 1, 2009)

     Hospital Indemnity Claim Form

     Cancer & Specified Disease Plan - Claim Form (Humana)

     Cancer Plan Well Care Benefit - Claim Form (Humana)

     Cancer & Specified Disease Plan Claim Form (Hartford Life Ins. Co.)

     Cancer & Specified Disease Plan Claim Form (National Union Fire Ins. Co.)

     Cancer Plan Well Care Benefit Claim Form (National Union Fire Ins. Co.)

     Assurant Indemnity Dental Claim Form

     Unum Disability Claim Form & Instructions for completion

     Unum Disability Medical Treatment Claim Form


Change Forms:

     Group Medical Insurance Change or Enrollment Form

     Basic & Supplemental Life Beneficiary Change Form

     Fortis Indemnity Dental Plan Change Form

     Prepaid Heritage DHMO Dental Change Form