Health Cost Solutions Logo

Forms

Title Description File Name
Group Enrollment Use this form for employee enrollment additions or changes. enrollment.pdf
Statement of Claim Use this form for submitting claims to Health Cost Solutions. stmtofclm.pdf
Request for Confidential Communications Use this form to request alternate or confidential communications. ConfComm.pdf
Request for Restrictions on Use or Disclosure of Protected Health Information For use to request a restriction on the use or disclosure of health information. restrict.pdf
Request for an Accounting of Certain Disclosures of Health Information For requesting an accounting of certain disclosures of protected health information. disclosures.pdf
Request for Amendment of Protected Health Information Use this form to request the addition of information to your health information. amendment.pdf
Request for Access to Protected Health Information To request access or copies of Protected Health Information access.pdf
FSA Dependent Care Reimbursement Form 
Use this form to submit eligible dependent care expenses for reimbursment. 
FSADepReimb.pdf 
FSA Health Care Expenses Reimbursement Form 
Use this form to submit health care expenses for reimbursment. 
FSAMedReimb.pdf