Completed forms must include a conventional written signature where required. The forms may be printed and then filled in or filled in and then printed. Completed forms should be routed as instructed by BPA or your employer. You can get the PDF viewer for free from Adobe.

Main Enrollment Form


Average Employee Count Form


Change Form


Claim Information Form


CMS Mandatory SSN Reporting Update Form


Dependent Eligibility Questionnaire


Incident Questionnaire


Flex Enrollment Form


Flex Change Form


Flex/HRA Reimbursement Form


Flexible Spending Brochure


Eligible Expenses FSA Medical Reimbursement Account


Eligible Over-The-Counter Meds FSA Medical Reimbursement Acct.


COBRA Group Coverage Continuation Notice Form


COBRA Flexible Compensation Program Continuation Notice Form


Duties of the HIPAA Privacy Officer


HIPAA Privacy Practices Complaint Form


HIPAA Gap Analysis Form


HIPAA Consent To Provide Information


Women’s Health & Cancer Rights Act Notice


How to Read Your Explanation of Benefits Statement


Incapacitated Child Form


Life Insurance Beneficiary Designation Form


CHIPRA Model Notice


Other Coverage Form


 

 Teladoc

 Teladoc Engagement Toolkit       BPA Notice of Teladoc Transition

American Health and Teladoc   FAQs – Transition to Teladoc

 Teladoc Updates for Employees


= Adobe PDF = Microsoft Word