Health Enrollment Forms

The following are the Health Enrollment and Request for Change forms, which you can fill out online, print, sign, and submit to your employer. The other enrollment related forms should be submitted directly to Allegiance. Just click on the first area to fill out and use the tab key (rather than enter) to move between fields. You will need Adobe Acrobat Reader 5 or better to view these forms.

	Health Enrollment Form
	Request for Change Form
	Alternate Payee Request Form
	Student Status Verification
	Dependent Disability Form
	Common Law Affidavit
	Change of Address

Health Claim Forms

Following are some frequently used Health Claim forms. These files must be viewed with Adobe Acrobat Reader version 5 or newer. To fill out the forms online, use the tab key (rather than enter) to move between fields. Once the forms are completed, print the forms, and submit them directly to Allegiance.

	Accident Questionnaire
	Authorization to Release Confidential Health Claim Info
	C.O.B. Questionnaire
	Disability Application
	Domestic / International Claim Form