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
P.O. Box 265 League City, TX 77574 Phone: (281) 333-9792 Fax: (281) 333-9223 E-mail: Estationins@aol.com