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   (English version)  (Spanish version)

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 Engagement Toolkit       BPA Notice of Teladoc Transition

American Health and Teladoc   FAQs – Transition to Teladoc

 Teladoc Updates for Employees

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