Plan Documents & Forms

Plan Documents & Amendments

Summary Plan Description & Plan Document

Forms

Anthem Member Claim Form
Change of Address
Continued Coverage for Incapacitated Child
COVID-19 OTC Reimbursement Claim Form
Enrollment Form
Kaiser Enrollment/Change Form
Short-Term Disability Form
UHC Dental Enrollment Form

Notices

Notice of Creditable Coverage

2022 NOCC

Other Notices

COBRA Notice
Kaiser Evidence of Coverage
Nondiscrimination Statement
Surprise Billing Notice (English)
Surprise Billing Notice (Spanish)
Women’s Health & Cancer Rights

Reports

2021 Summary Annual Report

Summary of Benefits & Coverage (SBC)

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