PLAN YEAR FORMS GUIDE

Transcription

1 PLAN YEAR FORMS GUIDE Listed below are the documents available via electronic access on your Employee Custom Website. 1. Login: 2. Select: My Tools 3. Select: MyBenefits on Demand 4. Select: Documents of Choice Member Let s Get Educated Rights and HSA Responsibilities Postcard» HSA Enrollment Form MyBenefits on Demand Order Form» HSA Change Form Sample Employer Member Supply Request Form» HSA Bank Employer Sign-Up Form Sample Annual Paper Provider Directory Order Form» HSA Bank Excess Contribution Removal Form Employee Healthcare Benefit Reminder» HSA IRS Form 1099-SA Instructions Sample ID Card and Request Form» HSA IRS Form 5498-SA Instructions Sample Explanation of Benefits (EOB) Other Insurance Form: English and Spanish Sample Explanation of Payment (EOP) Right of Recovery-Accident/Injury Form: English and Spanish Medical Section 125» Medical Enrollment Form» Section 125 Enrollment Forms:» Medical Change-Term Form Standard Plan, Premium Only, Grace Period, Carryover» Active Employee/Continuation of Coverage» Section 125 Change Forms: Participant and Dependent Eligibility Checklist Form Standard Plan, Premium Only, Grace Period, Carryover» Healthiest You Telehealth Group Enrollment Form» Section 125 Claim Form Dental and Vision Reimbursement Forms» Section 125 Dependent Care Reimbursement Forms: Consumer Centered Standard Plan, Grace Period, Carryover» Consumer Centered Medical Enrollment Form» Section 125 Unreimbursed Healthcare Reimbursement Forms:» Consumer Centered Medical Change-Term Form Standard Plan, Grace Period, Carryover» Consumer Centered HRA/HSA Enrollment Form» Section 125 Recurring Expense Service Form» Consumer Centered Benefit Calculator» Section 125 Direct Deposit Authorization Agreement HRA Six Steps to Understand Open Enrollment» HRA Enrollment Form COBRA Continuation of Coverage» HRA Change Form» COBRA Continuation of Coverage Enrollment Form» HRA Claim Form» COBRA Continuation of Coverage Employer's Termination RRA Notice Form» RRA Enrollment Form (If Post Deductible RRA for access to Consumer Centered Plans)» RRA Change Form» RRA Claim Form Political Subdivision Value Based Synergy Managing the Multi-Faceted Solutions to Healthcare Costs and Performance Based Outcome Rev TML MultiState IEBP Page 1 of 71

2 Helpful Resources Helpful Resources Resource TML MultiState Intergovernmental Employee Benefits Pool (IEBP) Contact Information and Accessible Hours Physical: 1821 Rutherford Lane, Suite 300 Austin, Texas Mailing: PO Box Austin, Texas Customer Care Helpline (800) :30 AM - 5:00 PM Central Secured Customer Care Medical Secured Customer Care Dental dental-mail@iebp.org Provider Benefit Information Portal: Provider information can be found under the Provider Services menu. Member specific information such as Eligibility, Claims, Summary of Benefits and Coverage, Provider Coding Guidelines, Medication Therapy Management Guide, Member Rights and Responsibilities, Provider/Member Appeal Rights and IEBP Quality Improvement Plan information is also available. Visit click on the "Login" button click on "Online Customer Care" under the "My Tools" menu click on "Send a Secure " 8:30 AM - 5:00 PM Central Visit to register, click on the "Sign Up" link under the provider section to login, click on the "Login" button at the top right hand side of the screen TML MultiState IEBP Internet Website Twenty-four (24) hrs MyIEBP Mobile Access iphone App Store, Droid Google Play, All other Phones Twenty-four (24) hrs Information on how IEBP evaluates new technology for inclusion as a Visit click on "About Us" click on "Technology" covered benefit Medical Authorizations (800) :30 AM - 5:00 PM Central Professional Health Coaches: Professional Health Coaches will answer basic health and medication questions and assist Covered Individuals with the Healthy Initiatives Incentive Program. Covered Individuals may enroll in professional health coaching. Spanish Line (888) :30 AM - 6:00 PM Central or Scheduled Appt. (800) Spanish_cc@iebp.org (There is an underscore between Spanish and cc.) Where to Mail Paper Medical Claims TML MultiState IEBP PO Box Austin, Texas After Hours and/or Weekend Medical and Mental Healthcare Call 911 or immediately go to the emergency department. Emergencies IEBP Performance Improvement Plan Visit click on the "Login" button click on "My Tools" click on "Quality Improvement Program" We want to hear from you! Our goal is to provide you with excellent Visit click on "TAKE OUR SURVEY" select the survey service. Please provide us with feedback on your experience specific to --- for the type of service you received from the list presented this claim. Thank you for your response. Rev TML MultiState IEBP Page 2 of 71

3 Table of Contents Helpful Resources... 2 Member Let s Get Educated Rights and Responsibilities Postcard... 5 MyBenefits on Demand Order Form... 6 Sample Member Supply Request Form... 7 Sample Annual Paper Provider Directory Order Form... 8 Employee Healthcare Benefit Reminder Sample ID Card and Online Request Form Sample ID Card Online ID Card Request Form Sample Explanation of Benefits (EOB) Sample Explanation of Payment (EOP) Medical Enrollment Form Medical Request for Change-Term Form Active Employee/Continuation of Coverage Participant and Dependent Eligibility Checklist Form Healthiest You Telehealth Group Enrollment Form Dental Reimbursement Form Vision Reimbursement Form Consumer Centered Medical Enrollment Form Consumer Centered Medical Request for Change-Term Form Consumer Centered HRA/HSA Enrollment Form Consumer Centered Benefit Calculator Health Reimbursement Arrangement (HRA) Enrollment Form HRA Request for Change HRA Claim Form Retirement Reimbursement Arrangement (RRA) Enrollment Form RRA Change Form RRA Claim Form Health Savings Account (HSA) Enrollment Form Rev TML MultiState IEBP Page 3 of 71

4 HSA Change Form HSA Bank Employer Sign-Up Form HSA Bank Excess Contribution Removal Form HSA IRS Form 1099-SA Instructions HSA IRS Form 5498-SA Instructions Other Insurance Form - English Other Insurance Form - Spanish Right of Recovery Accident/Injury Form - English Right of Recovery Accident/Injury Form - Spanish Section 125 Flex Enrollment Form - Standard Plan Section 125 Flex Enrollment Form - Grace Period Section 125 Flex Enrollment Form - Carryover Section 125 Premium Only Plan Enrollment Form Section 125 Flex Change Form - Standard Plan Section 125 Flex Change Form - Grace Period Section 125 Flex Change Form - Carryover Section 125 Premium Only Plan Change Form Section 125 Flex Claim Form Section 125 Flex Dependent Care Reimbursement Form - Standard Plan Section 125 Flex Dependent Care Reimbursement Form - Grace Period Section 125 Flex Dependent Care Reimbursement Form - Carryover Section 125 Flex Unreimbursed Reimbursement Form - Standard Plan Section 125 Flex Unreimbursed Reimbursement Form - Grace Period Section 125 Flex Unreimbursed Reimbursement Form - Carryover Section 125 Flex Recurring Expense Service Form Section 125 Direct Deposit Authorization Agreement Six Steps to Understand Open Enrollment COBRA Continuation of Coverage (COC) Enrollment Form COBRA COC Employer's Termination Notice Form Rev TML MultiState IEBP Page 4 of 71

5 Member Let s Get Educated Rights and Responsibilities Postcard Member Let s Get Educated Rights and Responsibilities Postcard MEMBER RIGHTS AND RESPONSIBILITIES Let's Get Educated! Information on how IEBP evaluates new technology for inclusion as a covered benefit. Summary of Benefits and Coverage (SBC) 1. Login: 1. Login: 2. Select: My Tools 2. Select: My Tools 3. Select: MyBenefits ondemand 3. Select: MyBenefits ondemand 4. Select: Benefits 4. Select: Benefits 5. Select: Medical 5. Select: Summary of Benefit 6. Summary of Benefits and Changes Coverage 6. Medical and SBC Summary of Modifications Medical Plan 1. Login: 1. Login: 2. Select: My Tools 2. Select: My Tools 3. Select: MyBenefits ondemand 3. Select: MyBenefits ondemand 4. Select: Benefits 4. Select: Benefits 5. Select: Medical 5. Select: Summary of Benefit 6. Medical Plan Book Changes 6. Medical and SBC Summary of Modifications Medication Therapy Management Program 1. Login: 1. Login: 2. Select: My Tools 2. Select: My Tools 3. Select: MyBenefits ondemand 3. Select: MyBenefits ondemand 4. Select: Helpful Guides 4. Select: Benefits 5. Select: TML MultiState IEBP 5. Select: Summary of Benefit Helpful Guides Changes 6. Medication Therapy 6. MTMP Summary of Management Guide Modifications Member Rights and Notice of Privacy Practices 1. Login: 2. Select: My Tools 3. Select: MyBenefits ondemand 4. Select: Helpful Guides 5. Select: TML MultiState IEBP Helpful Guides 6. Member Rights and Responsibilities Guide Medical Intelligence Health and Wellness 1. Login: 2. Select: My Tools 3. Select: MyBenefits ondemand 4. Select: Helpful Guides 5. Select: TML MultiState IEBP Helpful Guides 6. Medical Intelligence Health and Wellness Guide Quality Improvement Plan 1. Login: 2. Select: My Tools 3. Select: Quality Improvement Program 4. QI Management Plan Rev TML MultiState IEBP Page 5 of 71

6 MyBenefits on Demand Order Form TML MultiState IEBP (IEBP) Website: Employer Internet Access Instructions Go to and click the "Login" link in the upper right hand corner of your screen. Enter your username and password and click the "Login" button. Once inside of the myhealth Portal, hover over the HR Benefit Center menu and click on the "Supply Requests" link. As always, you may download any of our forms or guides from within the MyBenefits on Demand section of the HR Benefit Center menu. Please return this form to (Fax). Employer Name: Phone Number: : Signature: Printed Name: Annual Rerates The annual rerates will now be located under MyBenefits on Demand. Once you have logged into the myhealth Portal, hover over the HR Benefit Center and click on MyBenefits on Demand. Click on "Fund Contact", then "Blank Agreements" or "Signed Documents". Prior year rerates will be located within the Signed Documents section and your upcoming plan year rerate will be located within the Blank Agreements section. Fund Contacts Benefit Enrollment/Eligibility Benefits Helpful Guides Health & Wellness Required Executed Online Agreements/Documents MyBenefits on Demand will now contain a section for both Signed Documents and Blank Agreements. Under the Signed Documents section you will have access to all executed agreements that have been physically signed by your group. Under the Blank Agreements will be a list of agreements that you may fill out and submit online. Once they have been processed, they will begin to display in the Signed Documents section. The MyBenefits on Demand screen may be found under the HR Benefit Center within the myhealth Portal. Those agreements and documents include:» Human Resources/Fund Contact Healthcare Benefits Information Resource and Executed Agreements Guide MANDATORY DISTRIBUTION-PAPER For paper copy distribution, please complete below and return via fax. Summary of Benefits and Coverage (SBC) Medical Plan Book Medication Therapy Management Guide # of Paper Copies Member Rights and Alternate Plan Book Responsibilities Guide with Risk or Non-Risk Interlocal Agreement Annual Rerate Sheet/Online Instructions Protected Health Information Medical Intelligence Health and Retiree Benefit Plan Book HRA Pool Book Annual Health Reimbursement Arrangement Wellness Guide (HRA) Section 125 Pool Books Annual Retirement Reimbursement Member Postcard Flyer Grace Period with or without Arrangement (RRA) Qualifying Events Annual Health Savings Account (H.S.A.) Form H.S.A. IRS Form 1099 and 5498 SA Instructions Annual Section 125 Flex MANDATORY DISTRIBUTION-ELECTRONIC Standard/No Grace Period with or without Qualifying Events Carryover with or without Qualifying Annual COBRA Continuation of Coverage If you will be directing your staff to view the Events Life Benefit Parameter Agreement above Mandatory Distribution electronically, Premium Only with or without Certification of Mandatory Distribution of please complete the Employer Name, Phone Qualifying Events Benefit Books and Plan Information Number,, and Signature fields above Supply Request Form Summary of Benefit Plan Modifications and return via fax. ID Card Request Form Medical» Forms Guide Dental 2» Fund Contact E-Friendly Resource Guide Dental 3» Online Enrollment Conversion Guide Dental 4 Medical Plan Book Dental Plan Books Dental 2 Dental 3 Dental 4 Vision Plan Books Vision A Vision B Vision A Vision B Member Agreements Medication Therapy Management Program # of Paper Copies The following covered individual tools are located: Select: My Tools, Select MyBenefits on Demand, Select Documents of Choice.» Medical Plan Book» Summary of Benefits and Coverage (SBC)» Employee E-Friendly Resource Guide» Member Rights and Responsibilities Guide with Protected Health Information» Medical Intelligence Health and Wellness Guide» Medication Therapy Management Guide» Political Subdivision MemberCentric Guide» Healthcare Provider Tool Guide» Provider Care Path Pricing Transparency Guide» Retiree Benefits Guide» Supplemental Benefits Option Guide» Online Enrollment Conversion Guide» IEBP Quality Improvement Plan» Human Resources/Fund Contact Healthcare Benefits Information Resource and Executed Agreements Guide» Satisfaction Survey Information Guide Comprehensive Eligibility Guide Employee E-Friendly Resource Guide Forms Guide Fund Contact E-Friendly Resource Guide Healthcare Provider Tool Guide Human Resources/Fund Contact Healthcare Benefits Information Resource and Executed Agreements Guide Medical Intelligence Health and Wellness Guide Medication Therapy Management Guide Member Rights and Responsibilities Guide with Protected Health Information Online Enrollment Conversion Guide Political Subdivision MemberCentric Guide Provider Care Path Pricing Transparency Guide Retiree Benefits Guide Satisfaction Survey Information Guide Supplemental Benefits Option Guide # of Paper Copies Healthy Living Fact Sheets Asthma COPD Depression Diabetes Healthy Eating Heart Disease Managing Stress Men s Health Physical Activity Tobacco Cessation Women s Health» Medical Intelligence Health and Wellness Guide # of Paper Copies Please return BOTH PAGES of this form to (Fax). Rev TML MultiState IEBP Page 6 of 71

7 Sample Member Supply Request Form This form is located online at: Login, select "My Tools" "Online Forms". SEND TO: (Include City/Group Name) Large Orders Require Street Address DATE: REQUESTOR: PHONE #: MEDICAL PLAN YEAR QTY POSTERS QTY Medical Plan Book Employee Healthcare Benefit Reminder Poster Alternate Plan Book Health Coach Poster Summary of Benefits and Coverage Healthy Living Wellness Incentive Poster Summary of Benefit Plan Modifications HEALTHY INITIATIVES INFORMATION DENTAL PLAN YEAR Personal Health Record Dental II Book Healthy Living Fact Sheets Dental III Book Healthy Initiatives Engagement Resources Dental IV Book Summary of Benefit Plan Modifications OPEN ENROLLMENT RESOURCES VISION PLAN YEAR Six Steps to Understand Open Enrollment Vision Plan A Employee Enrollment Important Reminder Notice Vision Plan B Notice of Privacy Practices Summary of Benefit Plan Modifications Alegeus/WealthCare Debit Card Flyer (Consumer Driven Product) PRESCRIPTION INFORMATION FORMS OptumRx Prescription Mail Order Form Enrollment Form (Form #E001) (Medical/Dental/Vision) Medication Therapy Management Guide Request for Change-Term Form (Medical/Dental/Vision) COBRA CONTINUATION OF COVERAGE (COC) The Standard Enrollment/Change Form (Life/LTD/STD) COC Initial Notice The Standard - Medical Health Statement COC Qualifying Event Form Retiree Reimbursement Account Enrollment Form Employer's Termination Notice Retiree Reimbursement Account Change Form COC Enrollment Form (#E001-C) Retiree Reimbursement Account Claim Form FLEXIBLE SPENDING ACCOUNT PLAN YEAR Health Savings Account Enrollment Form Flexible Spending Account Standard Plan Document Health Savings Account Change Form Flexible Spending Account Grace Period Plan Document Health Reimbursement Account Enrollment Form Flexible Spending Account Carryover Plan Document Health Reimbursement Account Change Form Flexible Spending Account Premium Only Plan Document Health Reimbursement Account Claim Form Flexible Spending Account Enrollment Form Health Reimbursement Account Limited Post Deductible Enrollment Form Flexible Spending Account Change Form Accident/Injury Questionnaire Form Flexible Spending Account Direct Deposit Form Member Supply Request Form Flexible Spending Account Recurring Expense Service Form Health Information Authorization Form Flexible Spending Account Dependent Care Reimbursement Form Other Coverage Inquiry Form Flexible Spending Account Unreimbursed Healthcare Reimbursement Form Active Employee/Continuation of Coverage Participant and Dependent Eligibility Checklist Form Flexible Spending Account Claim Form RETIREE BENEFITS - CALENDAR YEAR 2017 PPN DIRECTORY Pre Sixty-five Retiree Plan Book TML MultiState IEBP/UMR/UHC Choice Plus Retiree Benefits Guide GUIDES Pre Sixty-five Enrollment Form Comprehensive Eligibility Guide Retiree Election Form Employee E-Friendly Resource Guide Pre Sixty-five Retiree and Dependent Eligibility Checklist Form Forms Guide Employer Retiree Option Sheet Fund Contact E-Friendly Resource Guide TML MultiState IEBP Pre Sixty-five Plan Brochure Healthcare Provider Tool Guide United Healthcare HMO Medical Rx 1 Brochure Human Resources/Fund Contact Healthcare Benefits Information Resource and Executed Agreements Guide United Healthcare HMO Medical Rx 2 Brochure Medical Intelligence Health and Wellness Guide United Healthcare Supplemental Medical Plan F Brochure Member Rights and Responsibilities Guide with Protected Health Information United Healthcare Supplemental Medical Plan K Brochure Online Enrollment Conversion Guide United Healthcare Supplemental Rx 1 Brochure Political Subdivision MemberCentric Guide United Healthcare Supplemental Rx 2 Brochure Provider Care Path Pricing Transparency Guide Satisfaction Survey Information Guide Filled: Supplemental Benefits Option Guide Initials: Comments: Rev TML MultiState IEBP Page 7 of 71

8 Sample Annual Paper Provider Directory Order Form FUND CONTACT GROUP NAME MAILING ADDRESS CITY TX ZIP RE: Provider Directory Order Form Region # Dear Fund Contact: The Provider Directory information is online at Annually, TML MultiState IEBP requests that the members identify the number of printed directories they would like to have on hand for distribution to their employee, eligible retiree and dependent population. Please remember, the printed Provider Directories are updated annually and the website is updated daily. If you are interested in receiving Paper Provider Directories, at no additional cost, please fill out this form and return it to Adam Martinez via fax at (512) Name of UnitedHealthCare Choice Plus Network Directory: ### Number of Directories Needed: Order Deadline: May 20, 2016 Directories will be shipped on June 30, 2016 Signature/Title To search for the most current listing of UnitedHealthCare network providers, go to and login to the mytml IEBP web portal. For more information, please refer to the attached Online Provider Search instructions. Search results may be printed at any time. Please contact me at (512) if you have any questions or other suggestions that can help to reduce waste. Sincerely, Susan L. Smith Executive Director Rev TML MultiState IEBP Page 8 of 71

9 Online Provider Search You can search by name, location and specialty, to name a few. 1. Click the Provider Search link found in the Benefit & Provider Info menu on the top. 2. Read through the notice that pops up and click Close to continue. 3. If you are a Choice Plus Network Group: Click on the Search the Choice Plus Network button under the Choice Plus Network and perform a Provider search on the UHC website. Find a Provider via Multiple Paths, including: 1. Google Style Search - Search Tips Enter one of the following: Physician Name: (Last, First) Group or clinic name Facility name Condition 2. Shortcut Links Physician Specialties Facilities Conditions 1 2 Rev TML MultiState IEBP Page 9 of 71

10 Google Style Search Use this type of search when you want the most specific results with the least number of clicks or if you don t know specifics and want to use the auto-complete functionality. The auto-complete in the Google-style search has been configured to search multiple dictionaries: Provider Names Specialty Names Condition Names Hospital Condition Names Searching in PO 7.0 uses the following methods to match text: String similarity, aka Levenshtein edit distance Starts with, aka Initial Character Matching Compound Matching Auto-complete functionality in the Google-style search offers suggestions for completing the word or sentence typed by the user. The typed text, in this example High, is used as input to find suitable suggestions. Those suggestions are supplied in a dropdown below the text box. A maximum of 25 items from each dictionary are displayed, regardless of how many suggestions are available. Specific Search High Plains Surgery Center Results Single result If your physicians name does not appear, then you will need to Enter a zip code and number of miles so the system can research again Rev TML MultiState IEBP Page 10 of 71

11 Narrow your results There are many ways you can narrow down your search results. You have options to change the zip code or proximity, filter on only Tier 1 Providers, the provider s gender, language, new patient status, specialty, or hospital affiliation. Premium Tier 1 Providers Look for the UnitedHealth Premium Tier 1 symbol to identify doctors who have been recognized for providing value. No two doctors are alike. When you re looking for a doctor, we provide tools and information to help you make a more confident health care decision. These Premium Tier 1 providers have met the criteria for quality and/or cost efficiency. Provider Profile Page To view more information on a particular provider, click on their name. This view give you detailed information such as their address and phone number, Tier 1 status, in or out of network status, and additional locations. Rev TML MultiState IEBP Page 11 of 71

12 Employee Healthcare Benefit Reminder Rev TML MultiState IEBP Page 12 of 71

13 Mashone Forms Guide PY16-17 Sample ID Card and Online Request Form Sample ID Card Online ID Card Request Form Rev TML MultiState IEBP Page 13 of 71

14 Sample Explanation of Benefits (EOB) Rev TML MultiState IEBP Page 14 of 71

15 Sample Explanation of Payment (EOP) Rev TML MultiState IEBP Page 15 of 71

16 Medical Enrollment Form PO Box Austin, Texas Fax: (512) Employer Unique Identification #/Social Security # Last Name First Name MI Coverage Effective Male Single Active of Hire Birth Female Married Retired Hours per week normally worked Job Title Covered by Employer s Prior Carrier? Yes or No Prior Effective EMPLOYEE COVERAGE INFORMATION AND MAILING ADDRESS Medical Dental Vision Alternate Plan Street City State Zip Code Preferred Contact Phone # DEPENDENT/SPOUSE COVERAGE INFORMATION Rev TML MultiState IEBP Page 16 of 71 Only the dependents listed below will have the coverage selected. A person who is an enrolled eligible employee shall not be considered as an eligible dependent. If you are adding a dependent for the first time, you attest that you will submit the Eligibility Checklist and the Required Document(s) for the dependent within 60 days of the coverage effective date or dependent/spouse eligibility and claims will be placed on hold. Supporting documentation must be submitted to IEBP. Select Coverage Last Name First Name MI Sex of Birth Medical Dental Vision Medical Dental Vision Medical Dental Vision Social Security # Lives with Employee Do you or any of your dependents being enrolled have insurance through another medical, prescription, and/or dental plan? Yes No If yes, please complete and attach the Other Insurance Inquiry form and submit with this form to your employer. Employee Acceptance I hereby request the coverage indicated, provided that I am or become eligible, and certify that the above information is correct. The Eligibility Checklist must be completed with supporting documentation for newly added dependents. Employee Declination/Waiver I hereby decline/waive the affordable medical benefit coverage offered by my employer. I acknowledge this decision prohibits access to the Insurance Marketplace subsidy offsets that are available for 100%-400% federal poverty level income recipients. Please return this form to your employer. Employer Accepted By Notes Yes No Yes No Yes No Legal/Business - Declination/Waiver is due to: Relation to Employee Code: s = spouse; nc = natural child; ac = adopted child; sc = step child; fc = foster child; gc = grandchild; lg = legal guardian/conservator; co = court ordered health coverage Is someone other than the employee legally obligated to carry dependent coverage? If yes, who? Relation to Employee Code Employer pays less than 75% of employee medical rates Employer offers an HMO plan and 80% of Pool participation requirement is met Employee is accessing spouse s medical plan and has submitted plan name, contact person & employer of plan information. An employee who is accessing a parental healthcare plan to the attained age of twenty-six will not be required to obtain IEBP benefits to meet the 100% participation requirement. TriCare/Champus Coverage Retiree Benefits from prior employment Tribal Benefit Coverage Sixty-five and older employees who are eligible to enroll in Medicare and are not in receipt of financial incentive for the Medicare enrollment An employee who is accessing another plan due to Full Time Equivalency status with two employers (30 hours a week, 130 hours a month or 120 seasonal days a year) Plan Name Employer Contact Person WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response.

17 Medical Request for Change-Term Form PO Box Austin, Texas Fax: (512) Employer Unique Identification #/Social Security # Last Name First Name MI Coverage Effective PLEASE MARK CHANGE DESIRED Add Coverage Indicated Below Drop Coverage Indicated Below Name Change (former name) Address Change Retired of Retirement Medicare Eligible Yes No If Yes, Medicare (HIC) Number Medicare Effective EMPLOYEE MAILING ADDRESS Street City State Zip Code Preferred Contact Phone # DEPENDENT/SPOUSE COVERAGE INFORMATION Rev TML MultiState IEBP Page 17 of 71 Only the dependents listed below will have the coverage selected. A person who is an enrolled eligible employee shall not be considered as an eligible dependent. If you are adding a dependent for the first time, you attest that you will submit the Eligibility Checklist and the Required Document(s) for the dependent within 60 days of the coverage effective date or dependent/spouse eligibility and claims will be placed on hold. Supporting documentation must be submitted to IEBP. Select Coverage Last Name First Name MI Sex of Birth Social Security # Medical Dental Vision Medical Dental Vision Medical Dental Vision Lives with Employee Do you or any of your dependents being enrolled have insurance through another medical, prescription, and/or dental plan? Yes No If yes, please complete and attach the Other Insurance Inquiry form and submit with this form to your employer. Employee Acceptance I hereby request the coverage indicated, provided that I am or become eligible, and certify that the above information is correct. The Eligibility Checklist must be completed with supporting documentation for newly added dependents. Employee Declination/Waiver I hereby decline/waive the affordable medical benefit coverage offered by my employer. I acknowledge this decision prohibits access to the Insurance Marketplace subsidy offsets that are available for 100%-400% federal poverty level income recipients. Please return this form to your employer. Employer Accepted By Yes No Yes No Yes No Reason for Add or Change Notes Legal/Business - Declination/Waiver is due to: Relation to Employee Code: s = spouse; nc = natural child; ac = adopted child; sc = step child; fc = foster child; gc = grandchild; lg = legal guardian/conservator; co = court ordered health coverage Is someone other than the employee legally obligated to carry dependent coverage? If yes, who? Relation to Employee Code Employer pays less than 75% of employee medical rates Employer offers an HMO plan and 80% of Pool participation requirement is met Employee is accessing spouse s medical plan and has submitted plan name, contact person & employer of plan information. An employee who is accessing a parental healthcare plan to the attained age of twenty-six will not be required to obtain IEBP benefits to meet the 100% participation requirement. TriCare/Champus Coverage Retiree Benefits from prior employment Tribal Benefit Coverage Sixty-five and older employees who are eligible to enroll in Medicare and are not in receipt of financial incentive for the Medicare enrollment An employee who is accessing another plan due to Full Time Equivalency status with two employers (30 hours a week, 130 hours a month or 120 seasonal days a year) Plan Name Employer Contact Person WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response.

18 Active Employee/Continuation of Coverage Participant and Dependent Eligibility Checklist Form The most updated form is located online at Login, select "My Tools" "MyBenefits ondemand" "Eligibility & Enrollment" "Eligibility Requirements". Place an (x) in valid eligibility boxes. STEP I Employee/Continuation of Coverage Participant Name (first, last): Employee Offered Coverage: Employer Name: Yes No Social Security #/Subscriber ID #: Group #: STEP II To receive coverage, IEBP must receive enrollment information within thirty-one (31) days of the commencement of employment regardless if the Employer has a waiting or a waiting and orientation period. If an employee is not enrolled within thirty-one (31) days of hire, the employee cannot be added to the Plan until the next Open Enrollment period or a qualifying event occurs. Event Deadline for Documentation Event Deadline for Documentation New Hire within 60 days of of Hire Annual Open Enrollment - Based on within 60 days of New Plan Year Effective Group Anniversary Initial Enrollment - New Group within 60 days of the New Groups Effective Qualifying Event within 60 days of the Qualifying Event COC (Continuation of Coverage) Enrollment Birth of a Child within 60 days of Birth STEP III Employee/Continuation of Coverage Participant Only Coverage Employee/Continuation of Coverage Participant + Dependent Coverage Dependent documentation requirements for benefits enrollment, change, and termination; adding dependent coverage - a social security number is required for all dependents covered under the group medical, dental &/or vision plan. STEP IV Dependent STEP V Supporting Documentation (required for dependent eligibility) Spouse Natural Child - to attained age 26 Step Child - to attained age 26 Adopted Child - to attained age 26 Foster Child - to attained age 26 Other Child - to attained age 26 Grandchild - to attained age 26 Incapacitated Child Marriage Certificate, or Certificate of Informal Marriage (issued by county clerk's office) or Joint Tax Return Birth Certificate Birth Certificate PLUS Marriage Certificate, or Joint Tax Return, or Certificate of Informal Marriage (issued by county clerk's office) (verification that the Employee is married to the child(ren's) parent) PLUS Divorce Decree (signed by Judge), or Custodial Orders (signed by Judge), or Attorney General (AG) Orders to determine who is ordered to carry coverage on child(ren) for claims purposes Birth Certificate and Court Issued Adoption Documents Birth Certificate and Court Issued Foster Documents Birth Certificate and Legal Guardianship/Conservatorship Documents (signed by Judge) Birth Certificate, Tax Records, and/or Legal Guardianship/Conservatorship Documents (signed by Judge) Birth Certificate and Social Security Disability Document STEP VI Qualifying Event STEP VII Supporting Documentation (copies acceptable) Divorce - Drop spouse and their child(ren) Divorce Decree (finalized, signed by Judge) Court Ordered Coverage/Benefits - Add Dependent Child(ren) Court Order Expires - Drop Dependent Child(ren) Ineligibility under Medicaid or SCHIP - Add Dependent Child(ren) Eligibility for Medicaid - Drop Spouse &/or Dependent Child(ren) Eligibility for Medicare - Drop Spouse Eligibility for Other Coverage - Regulated by the IRS Spouse Job Status Change - full time to part time, unpaid leave of absence, termination of employment, significant change (10% or more) in the benefit coverage of your spouse's health plan - Add Spouse & Dependent Child(ren) Birth Certificate and Divorce Decree (signed by Judge), or Custodial Orders (signed by Judge), or Attorney General Order Attorney General Order (if an AG order is on file with IEBP we must have a new order from AG office indicating child(ren) may be dropped), or Divorce Decree (signed by Judge), or Custodial Orders (signed by Judge) Copy of ineligibility letter with effective date from Medicaid or SCHIP PLUS appropriate dependent child documentation listed above Copy of eligibility letter with effective date from Medicaid Copy of eligibility letter (or Medicare Card) with effective date from Medicare Letter from Other Health Plan verifying enrollment Documentation from their Employer of the change with effective date PLUS Marriage Certificate, or Certificate of Informal Marriage (issued by county clerk's office), or Joint Tax Return and appropriate child documentation listed above STEP VIII TML MultiState Intergovernmental Employee Benefits Pool (IEBP) reserves the right to request proof of required eligibility documentation. The undersigned Employee affirms that (1) he or she is/was employed an average of at least 20 hours a week by the Employer; (2) all legal relationship(s) of a spouse and/or dependent enrolled in the Plan are based in fact and correctly represented; and (3) to the best of the Employee's knowledge, the supporting documentation of such relationship(s) are true and correct copies of what the documents purport to be and unaltered from the original source. Employee acknowledges that the enrollment form is a governmental record, and that misrepresentation of information in the enrollment form might be considered to be a felony. Employee also agrees that should coverage of a spouse and/or dependent be rescinded within federal requirements, Employee will reimburse IEBP for the amount of claims paid by IEBP for the coverage period rescinded. Rev TML MultiState IEBP Page 18 of 71

19 STEP IX Employee/Continuation of Coverage Participant Name (first, last): Social Security #/Subscriber ID #: Employee/Continuation of Coverage Participant Acceptance I hereby request the coverage indicated, provided that I am or become eligible, and certify that the above information is correct. The Eligibility Checklist must be completed with supporting documentation for newly added dependents. : : Employer Accepted Employer Name: Group #: By: : Employee Declination/Waiver I hereby decline/waive the affordable medical benefit coverage offered by my employer. I acknowledge this decision prohibits access to the Insurance Marketplace subsidy offsets that are available for 100%-400% federal poverty level income recipients. : : Dependents Declination/Waiver My eligible dependents identified below decline/waive the affordable medical benefit coverage offered by my employer. I acknowledge this decision prohibits access to the Insurance Marketplace subsidy offsets that are available for 100%-400% federal poverty level income recipients. I acknowledge that if I make any future application for coverage for my dependents or myself through my current employer, then all persons enrolled at that future time will be considered as late entrants. I affirm that neither my employer nor any other entity has offered any financial or other incentive in consideration for my declination/waiver of this coverage. Spouse Social Security Number of Birth (if SSN not available) Dependent Social Security Number of Birth (if SSN not available) Rev TML MultiState IEBP Page 19 of 71

20 Healthiest You Telehealth Group Enrollment Form Rev TML MultiState IEBP Page 20 of 71

21 Dental Reimbursement Form 1. Enter all requested information in the Patient information and Employee Information section. Claims may be delayed if information is missing. 2. Enter the name address and telephone number of the provider of services in the provider information section. 3. Attach all applicable bills and receipts. 4. Sign and date the claim form. Submission of this claim form does not guarantee payment for services. Send the completed claim form to: Mail to: TML MultiState IEBP PO Box Austin, TX Fax to: (512) PATIENT INFORMATION (Required) Last Name First Name M.I. Unique Identification #/Social Security # Street Address City State Zip Code Preferred Contact Phone # of Birth Gender Relationship to Employee Do you have any other dental insurance coverage? Yes No Name of other insurance If yes, please go online at and complete the other insurance questionnaire information. If no, have you updated any of your information within the last 12 months? If so, please go online to and update the Other Insurance questionnaire information to avoid any delay of your claim. Was treatment due to an accident? Yes No If yes, please go online at and complete the Accident Details questionnaire information to avoid any delay of your claim. To request a copy of the Other Insurance or Accident Detail questionnaire, please contact Customer Care at (800) , Monday-Friday from 8:30 am-5:00 pm. EMPLOYEE INFORMATION Last Name First Name M.I. Unique Identification #/Social Security # Street Address City State Zip Code Preferred Contact Phone # of Birth Gender Employer Name and Group # REQUEST FOR REIMBURSEMENT Please attach all applicable bills and receipts for verification of benefits. PROVIDER INFORMATION Provider Name Phone Street Address City State Zip Code Rev TML MultiState IEBP Page 21 of 71

22 Vision Reimbursement Form 1. Enter all requested information in the Patient information and Employee Information section. Claims may be delayed if information is missing. 2. Enter the name address and telephone number of the provider of services in the provider information section. 3. Attach the original itemized receipts, which include a breakdown of the services and/or material you received, including lens type i.e. single, vision, and bifocal if applicable. 4. Sign and date the claim form. Submission of this claim form does not guarantee payment for services. Send the completed claim form to: Mail to: TML MultiState IEBP PO Box Austin, TX Fax to: (512) PATIENT INFORMATION (Required) Last Name First Name M.I. Unique Identification #/Social Security # Street Address City State Zip Code Preferred Contact Phone # of Birth Gender Relationship to Employee Patient Status Is there another health benefit plan? EMPLOYEE INFORMATION Last Name First Name M.I. Unique Identification #/Social Security # Street Address City State Zip Code Preferred Contact Phone # of Birth Gender Employer Name and Group # REQUEST FOR REIMBURSEMENT Please enter amount charged. Remember to include paid receipt. Exam Frame Lenses Contacts of Service $ $ $ $ ** If lenses were purchased, please check type Single Bifocal Trifocal Progressive PROVIDER INFORMATION Provider Name Phone Street Address City State Zip Code Rev TML MultiState IEBP Page 22 of 71

23 Consumer Centered Medical Enrollment Form PO Box Austin, Texas Fax: (512) Employer Unique Identification #/Social Security # Last Name First Name MI Coverage Effective Male Single Active of Hire Birth Female Married Retired Hours per week normally worked Job Title Covered by Employer s Prior Carrier? Yes or No Prior Effective EMPLOYEE COVERAGE INFORMATION AND MAILING ADDRESS Dental Vision Alternate Plan Employee Mailing Address Street City State Zip Code Preferred Contact Phone # Dependent Alternate Address Street City State Zip Code Preferred Contact Phone # CONSUMER CENTERED POOL PLANS/MEDICAL BENEFITS AND PRESCRIPTION MAC A PLAN Plan Benefit Percentage Network/ Out of Network In-Network Deductible Individual In-Network Deductible Family In-Network Out of Pocket Individual In-Network Out of Pocket Family Office Visit Maximum Indiv Out of Pocket Medical and Prescription Copays accumulate Maximum Family Out of Pocket Medical and Prescription Copays accumulate P MAC A HRA Eligible 90 Hospital, 70/50 $0 $0 $3,000 $6,000 None $6,600 $13,200 P MAC A HRA Eligible 80/50 $500 $1,000 $2,000 $4,000 None $6,600 $13,200 P MAC A HRA Eligible 80/50 $500 $1,000 $3,000 $6,000 None $6,600 $13,200 P MAC A HRA Eligible 80/50 $750 $1,500 $3,000 $6,000 None $6,600 $13,200 P MAC A HRA Eligible 80/50 $1,000 $2,000 $3,000 $6,000 None $6,600 $13,200 H MAC A High Deductible Health Plan HSA Eligible 80/50 $1,500 $3,000 $4,000 $8,000 None $6,450 $12,900 H MAC A High Deductible Health Plan HSA Eligible 80/50 $2,500 $5,000 $3,000 $6,000 None $6,450 $12,900 DEPENDENT/SPOUSE COVERAGE INFORMATION Dependents will be eligible for employee selected Medical Plan. Only the dependents listed below will have the coverage selected. A person who is an enrolled eligible employee shall not be considered as an eligible dependent. If you are adding a dependent for the first time, you attest that you will submit the Eligibility Checklist and the Required Document(s) for the dependent within 60 days of the coverage effective date or dependent/spouse eligibility and claims will be placed on hold. Supporting documentation must be submitted to IEBP. Select Coverage Last Name First Name MI Sex Medical Dental Vision Medical Dental Vision Medical Dental Vision of Birth Social Security # Do you or any of your dependents being enrolled have insurance through another medical, prescription, and/or dental plan? Yes No If yes, please complete and attach the Other Insurance Inquiry form and submit with this form to your employer. Employee Acceptance I hereby request the coverage indicated, provided that I am or become eligible, and certify that the above information is correct. The Eligibility Checklist must be completed with supporting documentation for newly added dependents. Employee Declination/Waiver I hereby decline/waive the affordable medical benefit coverage offered by my employer. I acknowledge this decision prohibits access to the Insurance Marketplace subsidy offsets that are available for 100%-400% federal poverty level income recipients. Please return this form to your employer. Employer Accepted By Legal/Business - Declination/Waiver is due to: Lives with Employee Yes No Yes No Yes No Relation to Employee Code: s = spouse; nc = natural child; ac = adopted child; sc = step child; fc = foster child; gc = grandchild; lg = legal guardian/conservator; co = court ordered health coverage Is someone other than the employee legally obligated to carry dependent coverage? If yes, who? Reason for Add or Change Notes Employer pays less than 75% of employee medical rates Employer offers an HMO plan and 80% of Pool participation requirement is met Employee is accessing spouse s medical plan and has submitted plan name, contact person & employer of plan information. An employee who is accessing a parental healthcare plan to the attained age of twenty-six will not be required to obtain IEBP benefits to meet the 100% participation requirement. TriCare/Champus Coverage Retiree Benefits from prior employment Tribal Benefit Coverage Sixty-five and older employees who are eligible to enroll in Medicare and are not in receipt of financial incentive for the Medicare enrollment An employee who is accessing another plan due to Full Time Equivalency status with two employers (30 hours a week, 130 hours a month or 120 seasonal days a year) Plan Name Contact Person Employer Relation to Employee Code WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Rev TML MultiState IEBP Page 23 of 71

24 Consumer Centered Medical Request for Change-Term Form PO Box Austin, Texas Fax: (512) Employer Unique Identification #/Social Security # Last Name First Name MI Coverage Effective PLEASE MARK CHANGE DESIRED Add Coverage Indicated Below Drop Coverage Indicated Below Name Change (former name) Address Change Retired of Retirement Medicare Eligible Yes No If Yes, Medicare (HIC) Number Medicare Effective EMPLOYEE AND DEPENDENT MAILING ADDRESS Employee Mailing Address Dependent Alternate Address Street State Zip Code Preferred Contact Phone # Street City City State Zip Code Preferred Contact Phone # CONSUMER CENTERED POOL PLANS/MEDICAL BENEFITS AND PRESCRIPTION MAC A PLAN Plan Benefit Percentage Network/ Out of Network In-Network Deductible Individual In-Network Deductible Family In-Network Out of Pocket Individual In-Network Out of Pocket Family Office Visit Maximum Indiv Out of Pocket Medical and Prescription Copays accumulate Maximum Family Out of Pocket Medical and Prescription Copays accumulate P MAC A HRA Eligible 90 Hospital, 70/50 $0 $0 $3,000 $6,000 None $6,600 $13,200 P MAC A HRA Eligible 80/50 $500 $1,000 $2,000 $4,000 None $6,600 $13,200 P MAC A HRA Eligible 80/50 $500 $1,000 $3,000 $6,000 None $6,600 $13,200 P MAC A HRA Eligible 80/50 $750 $1,500 $3,000 $6,000 None $6,600 $13,200 P MAC A HRA Eligible 80/50 $1,000 $2,000 $3,000 $6,000 None $6,600 $13,200 H MAC A High Deductible Health Plan HSA Eligible 80/50 $1,500 $3,000 $4,000 $8,000 None $6,450 $12,900 H MAC A High Deductible Health Plan HSA Eligible 80/50 $2,500 $5,000 $3,000 $6,000 None $6,450 $12,900 DEPENDENT/SPOUSE COVERAGE INFORMATION Dependents will be eligible for employee selected Medical Plan. Only the dependents listed below will have the coverage selected. A person who is an enrolled eligible employee shall not be considered as an eligible dependent. If you are adding a dependent for the first time, you attest that you will submit the Eligibility Checklist and the Required Document(s) for the dependent within 60 days of the coverage effective date or dependent/spouse eligibility and claims will be placed on hold. Supporting documentation must be submitted to IEBP. Select Coverage Last Name First Name MI Sex of Birth Medical Dental Vision Medical Dental Vision Medical Dental Vision Social Security # Do you or any of your dependents being enrolled have insurance through another medical, prescription, and/or dental plan? Yes No If yes, please complete and attach the Other Insurance Inquiry form and submit with this form to your employer. Employee Acceptance I hereby request the coverage indicated, provided that I am or become eligible, and certify that the above information is correct. The Eligibility Checklist must be completed with supporting documentation for newly added dependents. Employee Declination/Waiver I hereby decline/waive the affordable medical benefit coverage offered by my employer. I acknowledge this decision prohibits access to the Insurance Marketplace subsidy offsets that are available for 100%-400% federal poverty level income recipients. Please return this form to your employer. Employer Accepted By Legal/Business - Declination/Waiver is due to: Lives with Employee Yes No Yes No Yes No Relation to Employee Code: s = spouse; nc = natural child; ac = adopted child; sc = step child; fc = foster child; gc = grandchild; lg = legal guardian/conservator; co = court ordered health coverage Is someone other than the employee legally obligated to carry dependent coverage? If yes, who? Reason for Add or Change Notes Employer pays less than 75% of employee medical rates Employer offers an HMO plan and 80% of Pool participation requirement is met Employee is accessing spouse s medical plan and has submitted plan name, contact person & employer of plan information. An employee who is accessing a parental healthcare plan to the attained age of twenty-six will not be required to obtain IEBP benefits to meet the 100% participation requirement. TriCare/Champus Coverage Retiree Benefits from prior employment Tribal Benefit Coverage Sixty-five and older employees who are eligible to enroll in Medicare and are not in receipt of financial incentive for the Medicare enrollment An employee who is accessing another plan due to Full Time Equivalency status with two employers (30 hours a week, 130 hours a month or 120 seasonal days a year) Plan Name Contact Person Employer Relation to Employee Code WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Rev TML MultiState IEBP Page 24 of 71

25 Consumer Centered HRA/HSA Enrollment Form PO Box Austin, Texas Fax: (512) Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new Preferred Contact Phone # Address of Birth Check One Male Female Check One Single Widowed Married Divorced Employed HRA OPTION Annually Monthly Employer Contribution for Health Reimbursement Arrangement $ $ The benefits of the plan have been thoroughly explained to me and I decline to participate. HSA OPTION Note: I elect to contribute to my HSA with a pre-tax salary reduction through my employer s Section 125 Cafeteria Plan, and authorize my employer to deduct the amounts as indicated from my salary and forward the funds to HSA Bank to deposit in my HSA. Contributions made by all parties to Health Savings Account (H.S.A.) cannot exceed the annual HSA limit set by the Internal Revenue Service: 2016 Annual H.S.A. Contribution Limits 2017 Annual H.S.A. Contribution Limits Individual $3,350 $3,400 Family $6,750 $6,750 Employee Monthly Contribution: $ of first HSA contribution: / / ( must be on or after the first day of your HSA-compatible health plan coverage or the first day of opening your HSA, whichever is later. Leaving the date blank will authorize your employer to determine the date on your behalf.) Accountholders must meet all of the qualifications noted below to be eligible to make an additional H.S.A. catch-up contribution of $1,000 above the annual maximum contribution. Health Savings accountholder Age 55 or older (regardless of when in the year an accountholder turns 55) Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated) Total Annual Employee Contribution: $ Total Annual Employer Contribution (if applicable): $ Your Total Annual Employee Election along with contributions from any other sources, including your employer, may not exceed the Annual Maximum Contribution amount set by the IRS. Contribution limits can be found at: or by visiting the IRS site at: By my signature below, I certify that I have enrolled, or plan to enroll, in an HSA-compatible health plan and that I am not covered under any other plan that would disqualify me from opening or contributing to my HSA. I understand that this form is provided for convenience purposes and that HSA Bank will not initiate contributions to my HSA, but will allow my employer or their authorized agent to initiate contributions to my account. I DO NOT want to contribute to my HSA through a pre-tax salary reduction. I understand that I can make after-tax contributions to my HSA online - through Internet Banking ( or by mailing a check with a contribution form. Employer Accepted WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Rev TML MultiState IEBP Page 25 of 71 By Please return this form to your employer.

26 Consumer Centered Benefit Calculator PO Box Austin, Texas (800) Employer s Defined Contribution Medical Employee Rate Medical Dependent Rate Dental Employee Rate Dental Dependent Rate Vision Employee Rate Vision Dependent Rate Total (add all Medical + Dental + Vision rates) HRA / HSA (If the Employer s Defined Contribution is more than the Total, enter the difference here) Payroll Deduction (If the Employer s Defined Contribution is less than the Total, enter the difference here) Form Disclaimer: This worksheet is only provided as a tool and is not intended for enrollment for any above mentioned benefits. Rev TML MultiState IEBP Page 26 of 71

27 PO Box Austin, Texas Fax: (512) Health Reimbursement Arrangement (HRA) Enrollment Form Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Street Address City State Zip Code Check here if new Preferred Contact Phone # Address of Birth Spouse Name (First, M.I.) Dependent Name (First, M.I.) Dependent Name (First, M.I.) Check One Male Female of Birth of Birth of Birth Check One Single Married Widowed Divorced Annually Employed Employer Contribution for Health Reimbursement Arrangement $ $ Monthly Dependent Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth I certify the above information to be correct and true to the best of my knowledge and that any child(ren) listed are dependents under Section 152 of the Internal Revenue Code. Employer Accepted By WAIVER OF PARTICIPATION: The benefits of the plan have been thoroughly explained to me and I decline to participate. WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Please return this form to your employer. Rev TML MultiState IEBP Page 27 of 71

28 HRA Request for Change PO Box Austin, Texas Fax: (512) Employer Name Employer Group # Unique Identification #/Social Security # Last Name First Name MI Change Effective PLEASE MARK CHANGE DESIRED Address Change Name Change (former name) Retired of Retirement Medicare Eligible Yes or No If Yes, Medicare (HIC) Number EMPLOYEE MAILING ADDRESS Medicare Effective Street City State Zip Code Preferred Contact Phone # Address DEPENDENT/SPOUSE COVERAGE INFORMATION Only the dependents listed below will have the coverage selected. The term dependent will not include any person who is eligible for coverage as an employee. Children may be covered under only one Employee s plan. Spouse Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth Annually Employer Contribution for Health Reimbursement Arrangement $ $ Monthly Employer Accepted Reason for Add or Change: By WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Please return this form to your employer. Rev TML MultiState IEBP Page 28 of 71

29 HRA Claim Form PO Box Austin, Texas Fax: (512) INSTRUCTIONS: Please complete this form for the submission of any EOBs, prescription orders or receipts. Number your EOBs and receipts to correspond with the Item # column in sections B, C and/or D. Fax form to (512) or mail form to TML MultiState IEBP. This form must be submitted with each EOB or receipt; claims will not be processed unless proper documentation is supplied. Please Note: Section B applies only to plans in which HRA Funds are available after meeting an HRA deductible. For more information about your plan, consult your enrollment materials, your HR Department or TML MultiState IEBP. Please complete this form if you a requesting a Manual Reimbursement. A. Account Holder Information* NAME Last First Middle Initial MAILING ADDRESS Street City State Zip Unique Identification #/Social Security # Employer Preferred Contact Phone # ( ) - B. EOBs for Proof of Deductible (necessary only for plans in which HRA Funds are available after meeting an HRA Deductible) Item # Provider Amount E1 / / E2 / / E3 / / E4 / / E5 / / C. Receipts For Reimbursement Please complete this section for any requests for manual reimbursements from your HRA funds. You must provide a corresponding receipt in order to be reimbursed. NOTE: Claims will first be reimbursed from any Flexible Spending Arrangement and then from any Health Reimbursement Arrangement. Item # Provider Amount R1 / / R2 / / R3 / / R4 / / R5 / / TOTAL D. Receipts For Pharmacy Purchases Please complete this section to accompany pharmacy receipts. You must provide receipts for all pharmacy purchases. Item # Provider Amount P1 / / P2 / / P3 / / P4 / / P5 / / E. Agreement and Signature* I certify that these eligible expenses have been incurred by me or my eligible dependent and are not for cosmetic purposes but for the treatment of an illness, injury, trauma, or medical condition. I understand that expenses incurred means the service has been provided that gave rise to the expense, regardless of when I am billed or charged for or pay for the service. The expenses have not been reimbursed and I will not seek reimbursement elsewhere. I understand that any amounts reimbursed may not be claimed on me or my spouse s income tax returns. I understand that I am not eligible for reimbursement before I have reached the HRA deductible set by my employer. I have received and read the printed material regarding the reimbursement accounts and under all of the provisions. / / MAIL TO: TML MultiState IEBP PO Box Austin, Texas FAX TO: TML MultiState IEBP (512) Please keep copies of all receipts, prescription orders and EOBs for your own records. For questions and concerns, please call TML MultiState IEBP at (800) * These sections are required. Use only Sections B, C and D as needed. Rev TML MultiState IEBP Page 29 of 71

30 PO Box Austin, Texas Fax: (512) Retirement Reimbursement Arrangement (RRA) Enrollment Form Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Street Address City State Zip Code Check here if new address Mailing Address City State Zip Code Check here if new address Preferred Contact Phone # Address of Birth Medicare Eligible Yes No Check One Male Female If Yes, Medicare (HIC) Number Check One Single Widowed Married Divorced Medicare Effective Employed Annually Monthly Employer Contribution for Retirement Reimbursement Arrangement $ $ DEPENDENT/SPOUSE COVERAGE INFORMATION Only the dependents listed below will have the coverage selected. The term dependent will not include any person who is eligible for coverage as an employee. Children may be covered under only one Employee s plan. Spouse Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth I certify the above information to be correct and true to the best of my knowledge and that any child(ren) listed are dependents under Section 152 of the Internal Revenue Code. By Employer Accepted WAIVER OF PARTICIPATION: The benefits of the plan have been thoroughly explained to me and I decline to participate. WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Please return this form to your employer. Rev TML MultiState IEBP Page 30 of 71

31 RRA Change Form PO Box Austin, Texas Fax: (512) Employer Name Employer Group # Unique Identification #/Social Security # Last Name First Name MI Change Effective PLEASE MARK CHANGE DESIRED Address Change Name Change (former name) Retired of Retirement Medicare Eligible Yes or No If Yes, Medicare (HIC) Number Medicare Effective Annually Monthly Employer Contribution for Retirement Reimbursement Arrangement $ $ EMPLOYEE MAILING ADDRESS Street City State Zip Code Preferred Contact Phone # Address DEPENDENT/SPOUSE COVERAGE INFORMATION Only the dependents listed below will have the coverage selected. The term dependent will not include any person who is eligible for coverage as an employee. Children may be covered under only one Employee s plan. Spouse Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth Dependent Name (First, M.I.) of Birth Employer Accepted Reason for Add or Change: By Notes: WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Please return this form to your employer. Rev TML MultiState IEBP Page 31 of 71

32 RRA Claim Form PO Box Austin, Texas Fax: (512) INSTRUCTIONS: Please complete this form for the submission of any EOBs, prescription orders or receipts. Number your EOBs and receipts to correspond with the Item # column in sections B, C and/or D. Fax form to (512) or mail form to TML MultiState IEBP. This form must be submitted with each EOB or receipt; claims will not be processed unless proper documentation is supplied. Please Note: Section B applies only to plans in which RRA Funds are available after meeting an RRA deductible. For more information about your plan, consult your enrollment materials, your HR Department or TML MultiState IEBP. A. Account Holder Information* NAME Last First Middle Initial MAILING ADDRESS Street City State Zip Unique Identification #/Social Security # Employer Preferred Contact Phone # ( ) - B. EOBs for Proof of Deductible (necessary only for plans in which RRA Funds are available after meeting an RRA Deductible) Item # Provider Amount E1 / / E2 / / E3 / / E4 / / E5 / / C. Receipts For Reimbursement Please complete this section for any requests for manual reimbursements from your RRA funds. You must provide a corresponding receipt in order to be reimbursed. NOTE: You may have to meet your RRA Deductible (see Section B above) before you are eligible for reimbursement. Consult your HR Department or TML MultiState IEBP for your plan info. Item # Provider Amount R1 / / R2 / / R3 / / R4 / / R5 / / TOTAL D. Receipts For Pharmacy Purchases Please complete this section to accompany pharmacy receipts. You must provide receipts for all pharmacy purchases. Item # Provider Amount P1 / / P2 / / P3 / / P4 / / P5 / / E. Agreement and Signature* I certify that these eligible expenses have been incurred by me or my eligible dependent and are not for cosmetic purposes but for the treatment of an illness, injury, trauma, or medical condition. I understand that expenses incurred means the service has been provided that gave rise to the expense, regardless of when I am billed or charged for or pay for the service. The expenses have not been reimbursed and I will not seek reimbursement elsewhere. I understand that any amounts reimbursed may not be claimed on my or my spouse s income tax returns. I understand that I am not eligible for reimbursement before I have reached the RRA deductible set by my employer. I have received and read the printed material regarding the reimbursement accounts and under all of the provisions. / / MAIL TO: TML MultiState IEBP PO Box Austin, Texas FAX TO: TML MultiState IEBP (512) Please keep copies of all receipts, prescription orders and EOBs for your own records. For questions and concerns, please call TML MultiState IEBP at (800) * These sections are required. Use only Sections B, C and D as needed. Rev TML MultiState IEBP Page 32 of 71

33 Health Savings Account (HSA) Enrollment Form PO Box Austin, Texas Fax: (512) Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new Preferred Contact Phone # Address of Birth Check One Male Female Check One Single Married Widowed Divorced Employed OPTION ONE Note: I elect to contribute to my HSA with a pre-tax salary reduction through my employer s Section 125 Cafeteria Plan, and authorize my employer to deduct the amounts as indicated from my salary and forward the funds to HSA Bank to deposit in my HSA. Contributions made by all parties to Health Savings Account (H.S.A.) cannot exceed the annual HSA limit set by the Internal Revenue Service: 2016 Annual H.S.A. Contribution Limits 2017 Annual H.S.A. Contribution Limits Individual $3,350 $3,400 Family $6,750 $6,750 Employee Monthly Contribution: $ of first HSA contribution: / / ( must be on or after the first day of your HSA-compatible health plan coverage or the first day of opening your HSA, whichever is later. Leaving the date blank will authorize your employer to determine the date on your behalf.) Accountholders must meet all of the qualifications noted below to be eligible to make an additional H.S.A. catch-up contribution of $1,000 above the annual maximum contribution. Health Savings accountholder Age 55 or older (regardless of when in the year an accountholder turns 55) Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated) Total Annual Employee Contribution: $ Total Annual Employer Contribution (if applicable): $ Your Total Annual Employee Election along with contributions from any other sources, including your employer, may not exceed the Annual Maximum Contribution amount set by the IRS. Contribution limits can be found at: or by visiting the IRS site at: By my signature below, I certify that I have enrolled, or plan to enroll, in an HSA-compatible health plan and that I am not covered under any other plan that would disqualify me from opening or contributing to my HSA. I understand that this form is provided for convenience purposes and that HSA Bank will not initiate contributions to my HSA, but will allow my employer or their authorized agent to initiate contributions to my account. OPTION TWO I DO NOT want to contribute to my HSA through a pre-tax salary reduction. I understand that I can make after-tax contributions to my HSA online - through Internet Banking ( or by mailing a check with a contribution form. WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Please return this form to your employer. Rev TML MultiState IEBP Page 33 of 71

34 HSA Change Form PO Box Austin, Texas Fax: (512) Employer Name Employer Group # Unique Identification #/Social Security # Last Name First Name MI Change Effective PLEASE MARK CHANGE DESIRED Beneficiary Change Indicated Below Address Change Name Change (former name) Retired of Retirement Medicare Eligible Yes or No If Yes, Medicare (HIC) Number Medicare Effective EMPLOYEE ADDRESSES Physical (Street) Address City State Zip Code Mailing (Street/PO Box) Address City State Zip Code Preferred Contact Phone # Address BENEFICIARY INFORMATION Primary Name Relationship of Birth Social Security # *Contingent Name Relationship of Birth Social Security # CONTRIBUTIONS *Applies if primary beneficiary is deceased when benefits are payable. Annually Monthly Employer Contribution for Health Savings Account Employee Contribution for Health Savings Account Employer Accepted Reason for Add or Change: By Notes: WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Please return this form to your employer. Rev TML MultiState IEBP Page 34 of 71

35 HSA Bank Employer Sign-Up Form Please complete all that apply. MGA: AIN: Marketing: SVC: 03 For HSA Bank Use Only BP ID: INSTRUCTIONS All fields are required unless otherwise noted. Please complete this form using your computer or print clearly, then return it to your TML MultiState IEBP representative. You can mail or fax it to: TML MultiState IEBP P.O. Box Austin, Texas Fax: (512) Be sure to keep a copy of this form. You will need your username to log in to the Employer Site. By completing the Employer Sign-Up Form, you will gain access to HSA Bank s Employer Administration Area, which is designed to help you manage your Health Savings Account (HSA) program. Your temporary password - within 2 business days. If you have questions please contact TML MultiState IEBP at (800) :30-5:00 CST Confidential Voice Mail after hours. COMPANY INFORMATION Company Name: Federal Tax ID#: Address: City: State: Zip Code: Phone: Fax: Number of Employees: Number of Employees electing an HSA: MAIN ADMINISTRATOR INFORMATION The Main Administrator is the only individual that will have full administrative rights to add other administrative users and assign rights for accessing or updating your account. If you wish to change your Main Administrator in the future, you must complete a Company/Main Administrator Update Form, which can be requested by calling HSA Bank Business Relations department at (866) First Name: Last Name: Phone: Extension: Fax: Select Username (min. 8 characters; letters and numbers only; username will be case sensitive): Your temporary password ( ed later) and username will be needed to log in to the Employer Administration Area for the first time. SET-UP PREFERENCES For information on your options, visit select the Employer tab and click on Determine Enrollment Method or Select Contribution Options. Additional information will also be included in your Welcome and Employer Manual. If you would like to change your enrollment method, please call Business Relations. Would you like to be signed up for Group Online Enrollment? Yes No Would you like to be invoiced for your employees monthly fees? Yes No Is the invoicing contact the same as the Main Administrator? Yes No * If your Main Administrator and invoicing contact are not the same, please provide the invoicing contact information below. First Name: Please invoice Attn: Accounting Company: TML MultiState IEBP tmlacctg@iebp.org Privacy, the USA PATRIOT Act, and the Employer Site At HSA Bank we respect and protect the confidentiality of customer information. Some of the information we request is required by a Federal law called the USA PATRIOT Act and regulations adopted by governmental agencies to implement it. This law requires HSA Bank to obtain, verify and record information that identifies each person or entity that opens an account. This information helps the government fight the funding of terrorism and money laundering activities. When you sign up for the Employer Site, we will ask you for your company s name and address. We will also ask you for an identification number such as your Social Security, EIN or Tax Identification number. This information will allow us to identify you. In some instances, we may also ask to see identifying documents. Please rest assured that all customer information is kept in the strictest confidence, unless required by law to be disclosed. Rev TML MultiState IEBP Page 35 of 71

36 HSA Bank Excess Contribution Removal Form Rev TML MultiState IEBP Page 36 of 71

37 HSA IRS Form 1099-SA Instructions Rev TML MultiState IEBP Page 37 of 71

38 Rev TML MultiState IEBP Page 38 of 71

39 HSA IRS Form 5498-SA Instructions Rev TML MultiState IEBP Page 39 of 71

40 Rev TML MultiState IEBP Page 40 of 71

41 Other Insurance Form - English This form is located online at: Login, select "My Tools" "Online Forms". FAILURE TO PROVIDE THIS INFORMATION WILL RESULT IN CLAIM PROCESSING DELAYS In order to consider any claims submitted under your plan, TML MultiState Intergovernmental Employee Benefits Pool (IEBP) requires information regarding Other Insurance which includes medical, prescription, and/or dental coverage. The information is required for each covered individual under an IEBP plan. Please note that this form will need to be completed each time you (or a dependent) have a change in Other Insurance coverage. To avoid delays in claims processing or provider prompt pay penalties, please immediately complete this form online at or mail the completed form to the address below. TML MultiState IEBP Contact Information Mail to: TML MultiState IEBP PO Box Austin, TX Fax to: (512) Online at: Call: (800) click Login My Tools Online Customer Care Send a Secure Telefónica en Español: (800) TML MultiState IEBP Member Information Employee Name: Employee Unique ID: Employer Name: Group #: Do you or any of your dependents covered under your IEBP plan also have coverage through another medical, prescription, and/or dental plan? Please list all covered individuals, including yourself, and note whether they have other insurance. You will need to complete the information in the chart below for each covered individual who is enrolled in an IEBP plan, whether or not they have other insurance. If additional dependents need to be listed, you should attach a second copy of this form with that information. Reminder: You can also complete this form online at: Other Insurance Coverage? Last Name First Name of Birth Relationship to Employee Yes No SELF Yes No Yes No Yes No Yes No 1. If you answered no on each covered individual listed, please sign this form and submit to the address above. 2. If you answered yes on any covered individual, please complete the Other Insurance Inquiry Addendum on the back of this form, sign, and submit to the address above. I certify that the information I have provided is true and correct. I understand that if any of the information I provided is misleading or false, I may lose coverage or be required to repay any benefits paid as a result of the misinformation. Signature of Employee or Dependent age 18 years or older completing this form PLEASE NOTE: YOU WILL NEED TO COMPLETE A NEW OTHER INSURANCE INQUIRY FORM EACH TIME YOU OR YOUR DEPENDENTS HAVE A CHANGE IN HEALTH BENEFIT COVERAGE OR IF A DEPENDENT IS ADDED. Rev TML MultiState IEBP Page 41 of 71

42 Other Insurance Inquiry Addendum Employee Name: Employee UID/SSN#: Employer: Please provide specific information regarding the Other Insurance for each of the covered individuals indicated with a "yes" on the previous page. For any dependents covered under a TML MultiState IEBP employer plan, you will need to provide copies of any court documents that pertain to the parental responsibilities of any covered dependents (i.e. divorce decree, court orders, custodial order, medical support orders, etc.) if you have not already submitted a copy. Note that you must submit the entire court document(s), if not previously submitted. *Type of Plan: (1) Employer Plan; (2) Medicare; (3) Group HMO Plan; (4) Medicaid/SCHIP; (5) Individual Plan; or (6) High Deductible HSA Plan Employee Name: Type of Plan* (See the above list): of Birth: Is this an Active, Retiree, or COBRA plan? Policyholder Name: Type of Coverage (Circle all that apply): Medical Dental Rx Other Insurance Subscriber #: Effective of Other Insurance: Other Insurance Carrier Name: Termination of Other Insurance (if applicable): Other Insurance Phone#: Other Insurance Group #: Spouse Name: Type of Plan* (See the above list): of Birth: Is this an Active, Retiree, or COBRA plan? Policyholder Name: Type of Coverage (Circle all that apply): Medical Dental Rx Other Insurance Subscriber #: Effective of Other Insurance: Other Insurance Carrier Name: Termination of Other Insurance (if applicable): Other Insurance Phone #: Other Insurance Group #: Complete the following questions, only if the Spouse is under the attained age of 26 and is covered under a parent and/or legal guardian s plan. Mother s Name: Father s Name: Mother s of Birth: Father s of Birth: Other Legal Guardian s Name (if applicable): Other Legal Guardian s of Birth: Other Legal Guardian s Relationship: Other Legal Guardian s Gender (M/F): Dependent #1 Name: Type of Plan* (See the above list): of Birth: Is this an Active, Retiree, or COBRA plan? Policyholder Name: Type of Coverage (Circle all that apply): Medical Dental Rx Other Insurance Subscriber #: Effective of Other Insurance: Other Insurance Carrier Name: Termination of Other Insurance (if applicable): Other Insurance Phone #: Other Insurance Group #: Dependent s Relationship to Employee: Is the Employee the Custodial Parent? Mother s Name: Father s Name: Mother s of Birth: Father s of Birth: Other Legal Guardian s Name (if applicable): Other Legal Guardian s of Birth: Other Legal Guardian s Relationship: Other Legal Guardian s Gender (M/F): Dependent #2 Name: Type of Plan* (See the above list): of Birth: Is this an Active, Retiree, or COBRA plan? Policyholder Name: Type of Coverage (Circle all that apply): Medical Dental Rx Other Insurance Subscriber #: Effective of Other Insurance: Other Insurance Carrier Name: Termination of Other Insurance (if applicable): Other Insurance Phone #: Other Insurance Group #: Dependent s Relationship to Employee: Is the Employee the Custodial Parent? Mother s Name: Father s Name: Mother s of Birth: Father s of Birth: Other Legal Guardian s Name (if applicable): Other Legal Guardian s of Birth: Other Legal Guardian s Relationship: Other Legal Guardian s Gender (M/F): NOTE: If there are more dependents, copy and attach additional form(s). Rev TML MultiState IEBP Page 42 of 71

43 Other Insurance Form - Spanish Cuestionario de otros seguros A fin de tener en consideración las reclamaciones presentadas bajo su plan, el Intergovernmental Employee Benefits Pool (IEBP) de TML MultiState necesita información sobre otros seguros que incluya la cobertura médica, de recetas o dental. La información es necesaria para cada individuo cubierto bajo un plan de IEBP. Tenga en cuenta que este formulario deberá completarse cada vez que usted (o un dependiente) tengan un cambio de cobertura de otro seguro. Para evitar demoras en el procesamiento de las reclamaciones o sanciones por no pronto pago a proveedores, complete inmediatamente este formulario en línea en o envíe por correo el formulario completado a la dirección indicada abajo. Información de contacto de TML MultiState IEBP Envíe por correo a: TML MultiState IEBP PO Box Austin, TX Envíe por fax al: (512) En línea en: Llame al: (800) Correo electrónico: haga clic en Inicio de sesión haga clic en Mis herramientas Atención al cliente en línea haga clic en Enviar un correo electrónico seguro Teléfono en español: (800) Información del miembro de TML MultiState IEBP Nombre del empleado: Id. único del empleado: Nombre del empleador: Nº de grupo: Usted o alguno de sus dependientes cubiertos por su plan IEBP tiene también cobertura a través de otro plan médico, de recetas o dental? Por favor, indique a todos los individuos cubiertos, incluyéndose usted, y señale si tienen otro seguro. Tendrá que completar la información de la tabla siguiente para cada persona cubierta que está inscrita en un plan IEBP, tengan o no otro seguro. Si necesitan enumerarse dependientes adicionales, debe adjuntar una segunda copia de este formulario con esa información. Recordatorio: También puede completar este formulario en línea en: Otra cobertura de seguros? Apellido Nombre Fecha de nacimiento Relación con el empleado Sí No EL MISMO Sí No Sí No Sí No Sí No 1. Si contestó no por cada persona cubierta indicada, firme este formulario y envíelo a la dirección anteriormente indicada. 2. Si contestó sí por cualquier persona cubierta, rellene el Anexo de cuestionario sobre otros seguros en el dorso de este formulario, fírmelo y envíelo a la dirección anteriormente indicada. Certifico que la información que he proporcionado es verdadera y correcta. Entiendo que si cualquier parte de la información que he suministrado es engañosa o falsa, puedo perder la cobertura o se me puede exigir que devuelva cualquier beneficio pagado como consecuencia de la mala información. Firma del empleado o dependiente de 18 años de edad o mayor que rellena este formulario TENGA ESTO PRESENTE: DEBERÁ RELLENAR UN NUEVO FORMULARIO DE CUESTIONARIO SOBRE OTROS SEGUROS CADA VEZ QUE USTED O SUS DEPENDIENTES TENGAN UN CAMBIO EN LA COBERTURA DE BENEFICIOS DE SALUD O SI SE AÑADE UN DEPENDIENTE. Rev TML MultiState IEBP Page 43 of 71 Fecha

44 Anexo de cuestionario de otros seguros Nombre del empleado: Nº UID/ SSN del empleado: Empleador: Proporcione información específica sobre el otro seguro por cada uno de los individuos cubiertos indicados con un Sí en la página anterior. En el caso de dependientes cubiertos bajo un plan de empleador TML MultiState IEBP, necesitará proporcionar copias de cualquier documento de un tribunal que se refiera a las responsabilidades paternas de cualquier dependiente cubierto (es decir, acta de divorcio, órdenes judiciales, orden de custodia, orden de sustento médico, etc.) si aún no ha entregado una copia. Tenga en cuenta que debe presentar todos los documentos del tribunal si no lo ha hecho previamente. *Tipo de plan: (1) Plan de empleador; (2) Medicare; (3) Plan HMO de grupo; (4) Medicaid/SCHIP; (5) Plan individual; o (6) Plan HSA de alto deducible Nombre del empleado: Fecha de nacimiento: Nombre del titular de la póliza: Suscriptor de otro seguro Nº: Nombre del otro asegurador: Número de teléfono del otro seguro: Tipo de plan* (vea la lista arriba): Éste es un plan activo, jubilado o COBRA? Tipo de cobertura (encierre en un círculo todas las que apliquen): Médica Dental Farmacia Fecha de vigencia del otro seguro: Fecha de finalización del otro seguro (de ser aplicable): Nº de grupo del otro seguro: Nombre del cónyuge: Tipo de plan* (vea la lista arriba): Fecha de nacimiento: Éste es un plan activo, jubilado o COBRA? Nombre del titular de la póliza: Tipo de cobertura (encierre en un círculo todas las que apliquen): Médica Dental Farmacia Suscriptor de otro seguro Nº: Fecha de vigencia del otro seguro: Nombre del otro asegurador: Fecha de finalización del otro seguro (de ser aplicable): Nº de teléfono del otro seguro: Nº de grupo del otro seguro: Responda las siguientes preguntas, sólo si el cónyuge tiene menos de la edad cumplida de 26 años y está cubierto por el plan de un padre o tutor legal. Nombre de la madre: Nombre del padre: Fecha de nacimiento de la madre: Fecha de nacimiento del padre: Nombre del otro tutor legal (de ser aplicable): Fecha de nacimiento del otro tutor legal: Relación con el otro tutor legal: Género del otro tutor legal (M/F): Nombre del dependiente Nº 1: Tipo de plan* (vea la lista arriba): Fecha de nacimiento: Éste es un plan activo, jubilado o COBRA? Nombre del titular de la póliza: Tipo de cobertura (encierre en un círculo todas las que apliquen): Médica Dental Farmacia Suscriptor de otro seguro Nº: Fecha de vigencia del otro seguro: Nombre del otro asegurador: Fecha de finalización del otro seguro (de ser aplicable): Nº de teléfono del otro seguro: Nº de grupo del otro seguro: Relación del dependiente con el empleado: Es el empleado el padre que tiene la custodia? Nombre de la madre: Nombre del padre: Fecha de nacimiento de la madre: Fecha de nacimiento del padre: Nombre del otro tutor legal (de ser aplicable): Fecha de nacimiento del otro tutor legal: Relación con el otro tutor legal: Género del otro tutor legal (M/F): Nombre del 2º dependiente: Tipo de plan* (vea la lista arriba) Fecha de nacimiento: Éste es un plan activo, jubilado o COBRA? Nombre del titular de la póliza: Tipo de cobertura (encierre en un círculo todas las que apliquen): Médica Dental Farmacia Suscriptor de otro seguro Nº: Fecha de vigencia del otro seguro: Nombre del otro asegurador: Fecha de finalización del otro seguro (de ser aplicable): Nº de teléfono del otro seguro: Nº de grupo del otro seguro: Relación del dependiente con el empleado: Es el empleado el padre que tiene la custodia? Nombre de la madre: Nombre del padre: Fecha de nacimiento de la madre: Fecha de nacimiento del padre: Nombre del otro tutor legal (de ser aplicable): Fecha de nacimiento del otro tutor legal: Relación con el otro tutor legal: Género del otro tutor legal (M/F): Nota: Si hay más dependientes, copie y adjunte formularios adicionales. Rev TML MultiState IEBP Page 44 of 71

45 Right of Recovery Accident/Injury Form - English This form is located online at: Login, select "My Tools" "Online Forms". TML MultiState Intergovernmental Employee Benefits Pool (IEBP) has received a claim for services that suggests you may have had an accident or injury. In order to consider this claim, this form must be completed and signed by you (or a parent or legal guardian if the patient is under 18 years of age) and received by IEBP. The information you provide is important as it helps IEBP find out if medical benefits are available from other sources. Please complete any and all relevant sections even if the services are not accident or injury related, and return it promptly to the address below to avoid delays in processing and/or an application of a covered individual prompt pay penalty due to IEBP s required compliance with the provider network Prompt Pay statute. Mail to: TML MultiState IEBP PO Box Austin, TX Fax to: Fax: (512) Online at: For questions or assistance with this form contact Customer Care: Call: (800) Visit click on the Login button click on Online Customer Care under the My Tools menu Telefónica en Español: (800) If you have already completed or submitted this form to IEBP, please contact Customer Care at (800) for verification that your completed form has been received before you resend. Information on Patient: Name: Address: Preferred Contact Phone #: Information on Covered Employee/Subscriber: Name: Employer s Name: Employee/Subscriber ID: Address: Preferred Contact Phone #: SECTION A: TREATMENT INFORMATION ( NOT APPLICABLE or N/A ARE NOT PROPER ANSWERS) 1. Please provide a brief description of why treatment was necessary of event that caused the injury/illness Name and Address or location of event Please give a brief description of what happened. (We need a description of the cause of the event even if no one else was involved.) 2. Were the police involved in this incident? Yes No Rev TML MultiState IEBP Page 45 of 71

46 3. Please check all boxes that apply to the reason for treatment: Injury at work Injury involving an automobile Injury at the patient s place of residence Sports injury (include waiver or name and address of sport organization) Slip/Fall Assault Treatment not related to an Accident/Injury Other Injury 4. If an injury was involved, was it related to a motor vehicle accident? Yes No (if no, move to question 5) Work vehicle involved during working hours? Yes No Was a Police Report filed? Yes No (if yes, please attach a copy) Please list the name, address and phone number of the owners and drivers of each of the vehicles involved in the accident. Name Address Telephone Vehicle 1 Owner: Vehicle 1 Driver: Vehicle 2 Owner: Vehicle 2 Driver: List the make, year and license number of vehicle the injured person was riding in or driving. Vehicle Make Vehicle Year Vehicle License Number Please provide any motor vehicle insurance information for ALL persons and vehicles involved, including your own personal motor vehicle insurance, regardless of who was at fault. Policy Holder Name Insurer/ Adjuster Insurer s Address Insurer s Telephone Policy/Claim Number 5. If an injury was involved, did it occur on someone else s property or premises? Yes No If yes, please list the name, address and telephone number of ALL persons, businesses or property owners involved. Name Address Telephone Please list the following information for any homeowners or liability insurance for person(s) listed above. Policy Holder Name Insurer/ Adjuster Insurer s Address Insurer s Telephone Policy/Claim Number Rev TML MultiState IEBP Page 46 of 71

47 6. If an accident occurred, did you retain an attorney? Yes No Please list the name, address and phone number of your attorney. Name Address Telephone SECTION B: SETTLEMENT/REIMBURSEMENT AGREEMENT Pursuant to the terms of the benefit plan and in consideration of payment of my claims, I agree to cooperate with the plan administrator, TML MultiState Intergovernmental Employee Benefits Pool (IEBP), by notifying IEBP of an accidental injury or illness and by providing information or executing documents requested by IEBP that are necessary for IEBP to recover the amount paid for benefits; I agree not to settle damages, whether by legal action, settlement or otherwise, without written permission of IEBP, and only after consultation with IEBP to determine the full and potential medical charges; I agree that should I settle for damages as a result of an injury/illness with a third party or insurer, prior to securing such written permission, IEBP and my employer s health benefits plan is relieved of any liability for medical expenses resulting from the injury/illness; I agree to reimburse IEBP immediately upon collection of damages whether by legal action, settlement or otherwise including, but not limited to, first party motor vehicle insurance of a person who is not an immediate family member and third party motor vehicle insurance; the amount of such reimbursement may be reduced only by the reasonable expenses of collection and only with the written consent of IEBP; I understand that IEBP may provide any medical bills or payment information related to the injury/illness to my attorney or any insurer who will be reimbursing IEBP for medical benefits; I agree to provide IEBP with a first lien on all proceeds recovered to the extent of benefits provided by IEBP; I agree to provide IEBP with a copy of any settlement agreement relating to this injury/illness; I agree that this agreement is performable in Travis County, Texas (unless otherwise stated in the benefit plan) and that any legal action concerning this agreement or the benefit plan shall be filed and resolved in that county; and I agree to all provisions of the benefit plan. If this form is signed by my attorney representative, a HIPAA form must be completed by me. No complete settlement of claim coverage will be made by IEBP without this form returned, completed by attorney s office to IEBP. To be eligible for any benefits under this plan, the injured person (or parent or guardian if the injured person is under 18 years of age) must sign and date this questionnaire. Signature Printed Name Rev TML MultiState IEBP Page 47 of 71

48 Right of Recovery Accident/Injury Form - Spanish Cuestionario de accidentes y lesiones TML MultiState Intergovernmental Employee Benefits Pool (IEBP) ha recibido una reclamación por servicios que sugiere que usted puede haber sufrido un accidente o lesión. Para tener en consideración esta afirmación, este formulario debe ser rellenado y firmado por usted (o un padre o tutor legal, si el paciente tiene menos de 18 años de edad) y ser recibido por IEBP. La información que proporcione es importante porque ayuda a IEBP a saber si hay beneficios médicos disponibles de otras fuentes. Complete todas y cada una de las secciones pertinentes incluso si los servicios no se relacionan con accidentes o lesiones y devuélvalo prontamente a la dirección que aparece abajo para evitar retrasos en el procesamiento o una solicitud de penalización por pronto pago de una cobertura individual debida al cumplimiento que exige IEBP con el estatuto de pronto pago de la red de proveedores. Envíe por correo postal a: TML MultiState IEBP PO Box Austin, TX Envíelo por fax a: Fax: (512) En línea en: Si tiene preguntas o desea asistencia con este formulario, comuníquese con Atención al Cliente: Llame al: (800) Correo electrónico a: Visite haga clic en el botón Inicio de sesión haga clic en Atención al cliente en línea bajo el menú Mis herramientas Teléfono en español: (800) Si ya ha completado o enviado este formulario a IEBP, póngase en contacto con Atención al Cliente al (800) para verificar que su formulario completado se haya recibido antes de volverlo a enviar. Información sobre el paciente: Información sobre el empleado o suscriptor cubiertos: Nombre: Nombre: Dirección: Nombre del empleador: Id. de empleado/suscriptor: Nº de teléfono de día: Dirección: Nº de teléfono de día: SECCIÓN A: INFORMACIÓN SOBRE EL TRATAMIENTO ( NO APLICABLE O N/A NO SON RESPUESTAS ADECUADAS) 1. Proporcione una breve descripción de por qué era necesario el tratamiento Fecha del evento que causó la lesión o enfermedad Nombre y dirección o ubicación del evento Proporcione una breve descripción de qué sucedió. (Necesitamos una descripción de la causa del evento incluso si nadie más estuvo implicado). 2. Se involucró la policía en este incidente? Sí No Rev TML MultiState IEBP Page 48 of 71

49 3. Marque todas las casillas que se apliquen al motivo del tratamiento: Lesiones en el trabajo Lesiones que implican un automóvil Lesiones en el lugar de residencia del paciente Lesiones deportivas (incluya una exención o el nombre y dirección de la organización deportiva) Resbalones o caídas Agresión Tratamiento no relacionado con un accidente o lesión Otras lesiones 4. Si sufrió una lesión, estuvo relacionada con un accidente de vehículo de motor? Sí No (si la respuesta es No, pase a la pregunta 5) Hubo un vehículo de trabajo involucrado durante horas de trabajo? Sí No Se presentó una denuncia policial? Sí No (si la respuesta es Sí, adjunte una copia) Indique los nombres, direcciones y números de teléfono de los propietarios y conductores de cada uno de los vehículos involucrados en el accidente. Propietario del vehículo 1: Conductor del vehículo 1: Propietario del vehículo 2: Conductor del vehículo 2: Nombre Dirección Teléfono Indique la marca, el año y el número de licencia del vehículo en el que iba la persona lesionada o que conducía. Marca del vehículo Año del vehículo Número de licencia del vehículo Proporcione cualquier información del seguro del vehículo automotor de TODAS las personas y vehículos involucrados, incluyendo el seguro de su propio vehículo automotor, independientemente de quién tuviese la culpa. Nombre del titular de la póliza Asegurador/ Ajustador Dirección del asegurador Teléfono del asegurador Número de póliza/reclamación 5. Si hubo una lesión, ocurrió en propiedad o establecimiento de otra persona? Sí No Si la respuesta es Sí, presente una lista con los nombres, direcciones y número de teléfono de TODAS las personas y propietarios de los negocios o propiedades involucrados. Nombre Dirección Teléfono Presente la siguiente información de cualquier seguro de propietario o de responsabilidad civil para las personas arriba indicadas. Nombre del titular de la póliza Asegurador/ Ajustador Dirección del asegurador Teléfono del asegurador Número de póliza/reclamación Rev TML MultiState IEBP Page 49 of 71

50 6. Si se produjo un accidente, contrató a un abogado? Sí No Indique el nombre, dirección y número de teléfono de su abogado. Nombre Dirección Teléfono SECCIÓN B: ACUERDO DE LIQUIDACIÓN O REEMBOLSO Conforme a los términos del plan de beneficios y en consideración del pago de mis reclamaciones, estoy de acuerdo en cooperar con el administrador del plan, TML MultiState Intergovernmental Employee Benefits Pool (IEBP), notificándole a IEBP de una lesión accidental o enfermedad y proporcionando información o firmando los documentos solicitados por IEBP que sean necesarios para que IEBP recupere el importe pagado por beneficios; Estoy de acuerdo en no conciliar los daños y perjuicios, ya sea por acción legal, conciliación o de otra manera, sin el permiso escrito de IEBP, y sólo después de consultar con IEBP a fin de determinar los cargos médicos completos y potenciales; Estoy de acuerdo en que, si yo hiciera una conciliación por los daños y perjuicios como consecuencia de una lesión o enfermedad con un tercero o compañía de seguros, antes de asegurar tal permiso por escrito, IEBP y el plan de beneficios de salud de mi empleador quedan liberados de cualquier responsabilidad por gastos médicos derivados de la lesión o enfermedad; Me comprometo a reembolsar a IEBP inmediatamente al momento de la cobranza de daños y perjuicios ya sea por acción legal, conciliación o de otra forma, lo que incluye, entre otros, el seguro de vehículo automotor de primera parte de una persona que no sea miembro de su familia inmediata y seguro de vehículo automotor de terceros; la cantidad de tal reembolso sólo puede reducirse por los gastos razonables de cobranza y sólo con el consentimiento por escrito de IEBP; Entiendo que IEBP puede proporcionar cualquier factura médica o información de pago relacionadas con la lesión o enfermedad a mi abogado o a cualquier asegurador que vaya a reembolsar a IEBP los beneficios médicos; Estoy de acuerdo en proporcionar a IEBP un primer gravamen sobre todos los dineros que se recuperen en la medida de los beneficios proporcionados por IEBP; Estoy de acuerdo en proporcionar a IEBP una copia de cualquier acuerdo de conciliación relativo a esta lesión o enfermedad; Acepto que este acuerdo es ejecutable en el Condado de Travis, Texas (salvo que se indique otra cosa en el plan de beneficios) y que cualquier acción legal con respecto a este acuerdo o el plan de beneficios será presentada y resuelta en ese condado, y estoy de acuerdo con todas las disposiciones del plan de beneficios. Si este formulario está firmado por mi abogado representante, yo debo rellenar un formulario HIPAA. IEBP no hará ninguna conciliación completa de la cobertura de reclamaciones sin que se le devuelva este formulario, rellenado y completado por la oficina de un abogado. A fin de ser elegible para los beneficios según este plan, la persona lesionada (o padre o tutor si la persona lesionada es menor de 18 años de edad) debe firmar y fechar este cuestionario. Firma Fecha Nombre en letra de imprenta Rev TML MultiState IEBP Page 50 of 71

51 Section 125 Flex Enrollment Form - Standard Plan PO Box Austin, Texas Fax: (512) Standard Plan Plan Year: Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Employee Preferred Contact Phone # Employee Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new of Birth Check One Male Female Check One Single Married Widowed Divorced Employed Spouse Name (First, M.I.) of Birth I request that my salary be reduced as follows: Dependent Name (First, M.I.) Dependent Name (First, M.I.) Dependent Name (First, M.I.) of Birth of Birth of Birth Annually Contribution for Medical Coverage $ $ Contribution for Dental Coverage $ $ Other Contributions (SPECIFY) $ $ Monthly Dependent Name (First, M.I.) of Birth Unreimbursed Healthcare Expenses $ $ Dependent Care Expense (DCA) $ $ Total Authorized Reductions $ $ AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws. I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have thirty-one (31) days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML MultiState Intergovernmental Employee Benefits Pool. I agree to only submit claims which qualify as medical expenses under Section 213, Internal Revenue Code or dependent care expenses under Section 129, Internal Revenue Code. I accept: Pre-tax Premium Only Unreimbursed Healthcare DCA Unreimbursed Capital Health Expense WAIVER OF PARTICIPATION: The benefits of the plan have been thoroughly explained to me and I decline to participate. WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Please return this form to your employer. Rev TML MultiState IEBP Page 51 of 71

52 Section 125 Flex Enrollment Form - Grace Period PO Box Austin, Texas Fax: (512) Grace Period Plan Plan Year: Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Employee Preferred Contact Phone # Employee Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new of Birth Check One Check One Employed Male Single Widowed Female Married Divorced Spouse Name (First, M.I.) of Birth I request that my salary be reduced as follows: Dependent Name (First, M.I.) Dependent Name (First, M.I.) Dependent Name (First, M.I.) of Birth of Birth of Birth Annually Contribution for Medical Coverage $ $ Contribution for Dental Coverage $ $ Other Contributions (SPECIFY) $ $ Monthly Dependent Name (First, M.I.) of Birth Unreimbursed Healthcare Expenses $ $ Dependent Care Expense (DCA) $ $ Total Authorized Reductions $ $ AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws with additional two (2) month-fifteen (15) day grace period. I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have thirty-one (31) days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML MultiState Intergovernmental Employee Benefits Pool. I agree to only submit claims which qualify as medical expenses under Section 213, Internal Revenue Code or dependent care expenses under Section 129, Internal Revenue Code. I accept: Pre-tax Premium Only Unreimbursed Healthcare DCA Unreimbursed Capital Health Expense WAIVER OF PARTICIPATION: The benefits of the plan have been thoroughly explained to me and I decline to participate. WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Please return this form to your employer. Rev TML MultiState IEBP Page 52 of 71

53 Section 125 Flex Enrollment Form - Carryover PO Box Austin, Texas Fax: (512) Carryover Plan Plan Year: Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Employee Preferred Contact Phone # Employee Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new of Birth Check One Check One Employed Male Single Widowed Female Married Divorced Spouse Name (First, M.I.) of Birth I request that my salary be reduced as follows: Dependent Name (First, M.I.) Dependent Name (First, M.I.) Dependent Name (First, M.I.) of Birth of Birth of Birth Annually Contribution for Medical Coverage $ $ Contribution for Dental Coverage $ $ Other Contributions (SPECIFY) $ $ Monthly Dependent Name (First, M.I.) of Birth Unreimbursed Healthcare Expenses $ $ Dependent Care Expense (DCA) $ $ Total Authorized Reductions $ $ AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws unless my employer has authorized a carryover pursuant to IRS Notice I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have thirty-one (31) days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML MultiState Intergovernmental Employee Benefits Pool. I agree to only submit claims which qualify as medical expenses under Section 213, Internal Revenue Code or dependent care expenses under Section 129, Internal Revenue Code. I accept: Pre-tax Premium Only Unreimbursed Healthcare DCA Unreimbursed Capital Health Expense WAIVER OF PARTICIPATION: The benefits of the plan have been thoroughly explained to me and I decline to participate. WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Please return this form to your employer. Rev TML MultiState IEBP Page 53 of 71

54 Section 125 Premium Only Plan Enrollment Form PO Box Austin, Texas Fax: (512) Premium Only Plan Plan Year: Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Employee Preferred Contact Phone # Employee Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new of Birth Check One Male Female Check One Single Married Widowed Divorced Employed Spouse Name (First, M.I.) of Birth I request that my salary be reduced as follows: Annually Monthly Dependent Name (First, M.I.) Dependent Name (First, M.I.) Dependent Name (First, M.I.) Dependent Name (First, M.I.) of Birth of Birth of Birth of Birth Contribution for Medical Coverage $ $ Contribution for Dental Coverage $ $ Other Contributions (SPECIFY) $ $ Total Authorized Reductions $ $ AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws. I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have thirty-one (31) days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML MultiState Intergovernmental Employee Benefits Pool. I agree to only submit claims which qualify as medical expenses under Section 213, Internal Revenue Code or dependent care expenses under Section 129, Internal Revenue Code. WAIVER OF PARTICIPATION: The benefits of the plan have been thoroughly explained to me and I decline to participate. WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Please return this form to your employer. Rev TML MultiState IEBP Page 54 of 71

55 Section 125 Flex Change Form - Standard Plan PO Box Austin, Texas Fax: (512) Standard Plan Plan Year: Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Employee Preferred Contact Phone # Employee Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new Effective of Change Reason for Change ADD OR REMOVE FAMILY MEMBERS: (COMPLETE BELOW) Add Change Name (First, M.I.) Relation of Birth Add Change Name (First, M.I.) Relation of Birth CHANGE IN COVERAGE TYPE: (COMPLETE BELOW) Coverage Medical Contribution Add Remove Dental Contribution Add Remove Unreimbursed Health Care Expense Add Remove Dependent Care Expense (DCA) Add Remove Other Contribution (Please specify) Add Remove Change Increase Decrease Increase Decrease Increase Decrease Increase Decrease Increase Decrease From Pledge Amount Monthly Amount Pledge Amount Monthly Amount To AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws. I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have thirty-one (31) days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML MultiState Intergovernmental Employee Benefits Pool. I agree to only submit claims which qualify as medical expenses under Section 213, Internal Revenue Code or dependent care expenses under Section 129, Internal Revenue Code. WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Please return this form to your employer. Rev TML MultiState IEBP Page 55 of 71

56 Section 125 Flex Change Form - Grace Period PO Box Austin, Texas Fax: (512) Grace Period Plan Plan Year: Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Employee Preferred Contact Phone # Employee Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new Effective of Change Reason for Change ADD OR REMOVE FAMILY MEMBERS: (COMPLETE BELOW) Add Change Name (First, M.I.) Relation of Birth Add Change Name (First, M.I.) Relation of Birth CHANGE IN COVERAGE TYPE: (COMPLETE BELOW) Coverage Medical Contribution Add Remove Dental Contribution Add Remove Unreimbursed Health Care Expense Add Remove Dependent Care Expense (DCA) Add Remove Other Contribution (Please specify) Add Remove Change Increase Decrease Increase Decrease Increase Decrease Increase Decrease Increase Decrease From Pledge Amount Monthly Amount Pledge Amount Monthly Amount To AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws with additional two (2) month-fifteen (15) day grace period. I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have thirty-one (31) days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML MultiState Intergovernmental Employee Benefits Pool. I agree to only submit claims which qualify as medical expenses under Section 213, Internal Revenue Code or dependent care expenses under Section 129, Internal Revenue Code. WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Please return this form to your employer. Rev TML MultiState IEBP Page 56 of 71

57 Section 125 Flex Change Form - Carryover PO Box Austin, Texas Fax: (512) Carryover Plan Plan Year: Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Employee Preferred Contact Phone # Employee Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new Effective of Change Reason for Change ADD OR REMOVE FAMILY MEMBERS: (COMPLETE BELOW) Add Change Name (First, M.I.) Relation of Birth Add Change Name (First, M.I.) Relation of Birth CHANGE IN COVERAGE TYPE: (COMPLETE BELOW) Coverage Medical Contribution Add Remove Dental Contribution Add Remove Unreimbursed Health Care Expense Add Remove Dependent Care Expense (DCA) Add Remove Other Contribution (Please specify) Add Remove Change Increase Decrease Increase Decrease Increase Decrease Increase Decrease Increase Decrease From Pledge Amount Monthly Amount Pledge Amount Monthly Amount To AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws unless my employer has authorized a carryover pursuant to IRS Notice I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have thirty-one (31) days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML MultiState Intergovernmental Employee Benefits Pool. I agree to only submit claims which qualify as medical expenses under Section 213, Internal Revenue Code or dependent care expenses under Section 129, Internal Revenue Code. WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Please return this form to your employer. Rev TML MultiState IEBP Page 57 of 71

58 Section 125 Premium Only Plan Change Form PO Box Austin, Texas Fax: (512) Premium Only Plan Plan Year: Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Employee Preferred Contact Phone # Employee Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new Effective of Change Reason for Change ADD OR REMOVE FAMILY MEMBERS: (COMPLETE BELOW) Add Change Name (First, M.I.) Relation of Birth Add Change Name (First, M.I.) Relation of Birth CHANGE IN COVERAGE TYPE: (COMPLETE BELOW) Coverage Add Medical Contribution Remove Add Dental Contribution Remove Add Other Contribution (Please specify) Remove Change Increase Decrease Increase Decrease Increase Decrease From Pledge Amount Monthly Amount Pledge Amount Monthly Amount To AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws. I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have thirty-one (31) days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML MultiState Intergovernmental Employee Benefits Pool. I agree to only submit claims which qualify as medical expenses under Section 213, Internal Revenue Code or dependent care expenses under Section 129, Internal Revenue Code. WE WANT TO HEAR FROM YOU! Our goal is to provide you with excellent service. Please provide us with feedback on your experience specific to this claim. Just log in to and click on TAKE OUR SURVEY. Select the survey for the type of service you received from the list presented. Thank you for your response. Please return this form to your employer. Rev TML MultiState IEBP Page 58 of 71

59 Section 125 Flex Claim Form PO Box Austin, Texas Fax: (512) INSTRUCTIONS: Please complete this form for the submission of any EOBs, prescription orders or receipts. Number your EOBs and receipts to correspond with the Item # column in sections B, C and/or D. Fax form to (512) or mail form to TML MultiState IEBP. This form must be submitted with each EOB or receipt; claims will not be processed unless proper documentation is supplied. Please Note: Section B applies only to plans in which Flexible Spending Funds are available after meeting a Flexible Spending deductible. For more information about your plan, consult your enrollment materials, your HR Department or TML MultiState IEBP. A. Account Holder Information* NAME Last First Middle Initial MAILING ADDRESS Street City State Zip Unique Identification #/Social Security # Employer Preferred Contact Phone # ( ) - B. EOBs for Proof of Deductible (necessary only for plans in which Flexible Spending Funds are available after meeting a Flexible Spending Deductible) Item # Provider E1 / / E2 / / E3 / / E4 / / E5 / / C. Receipts For Reimbursement Please complete this section for any requests for manual reimbursements from your Flexible Spending funds. You must provide a corresponding receipt in order to be reimbursed. NOTE: You may have to meet your Flexible Spending Deductible (see Section B above) before you are eligible for reimbursement. Consult your HR Department or TML MultiState IEBP for your plan info. Item # Provider Amount R1 / / R2 / / R3 / / R4 / / R5 / / D. Receipts For Pharmacy Purchases Please complete this section to accompany pharmacy receipts. You must provide receipts for all pharmacy purchases. Item # Provider P1 / / P2 / / P3 / / P4 / / P5 / / E. Agreement and Signature* I certify that these eligible expenses have been incurred by me or my eligible dependent and are not for cosmetic purposes but for the treatment of an illness, injury, trauma, or medical condition. I understand that expenses incurred means the service has been provided that gave rise to the expense, regardless of when I am billed or charged for or pay for the service. The expenses have not been reimbursed and I will not seek reimbursement elsewhere. I understand that any amounts reimbursed may not be claimed on me or my spouse s income tax returns. I understand that I am not eligible for reimbursement before I have reached the Flexible Spending deductible set by my employer. I have received and read the printed material regarding the reimbursement accounts and under all of the provisions. MAIL TO: TML MultiState IEBP PO Box Austin, Texas FAX TO: TML MultiState IEBP (512) TOTAL / / Please keep copies of all receipts, prescription orders and EOBs for your own records. For questions and concerns, please call TML MultiState IEBP at (800) * These sections are required. Use only Sections B, C and D as needed. Rev TML MultiState IEBP Page 59 of 71

60 Section 125 Flex Dependent Care Reimbursement Form - Standard Plan PO Box Austin, Texas Fax: (512) Standard Plan Plan Year: Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new Name of Individual or Organization providing Dependent Care Services Name Name Name Tax ID or SS# Incurred Amt to be Reimbursed $ $ $ TOTAL $ Expense for care of: (Name) AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws. I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have thirty-one (31) days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML MultiState Intergovernmental Employee Benefits Pool. I certify that the expenses listed above qualify as expenses under Section 129, Internal Revenue Code. Statement of Certification: I certify that I have provided care for to. My charge for this service was. s child (children or dependent) from Name and Address of Provider Provider s Signature Tax ID or SS# Please return this form to TML MultiState IEBP. Rev TML MultiState IEBP Page 60 of 71

61 Section 125 Flex Dependent Care Reimbursement Form - Grace Period PO Box Austin, Texas Fax: (512) Grace Period Plan Plan Year: Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new Name of Individual or Organization providing Dependent Care Services Name Name Name Tax ID or SS# Incurred Amt to be Reimbursed $ $ $ Expense for care of: (Name) TOTAL $ AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws with additional two (2) month-fifteen (15) day grace period. I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have thirty-one (31) days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML MultiState Intergovernmental Employee Benefits Pool. I certify that the expenses listed above qualify as expenses under Section 129, Internal Revenue Code. Statement of Certification: I certify that I have provided care for to. My charge for this service was. s child (children or dependent) from Name and Address of Provider Provider s Signature Tax ID or SS# Please return this form to TML MultiState IEBP. Rev TML MultiState IEBP Page 61 of 71

62 Section 125 Flex Dependent Care Reimbursement Form - Carryover PO Box Austin, Texas Fax: (512) Carryover Plan Plan Year: Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new Name of Individual or Organization providing Dependent Care Services Name Name Name Tax ID or SS# Incurred Amt to be Reimbursed $ $ $ Expense for care of: (Name) TOTAL $ AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws unless my employer has authorized a carryover pursuant to IRS Notice I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have thirty-one (31) days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML MultiState Intergovernmental Employee Benefits Pool. I certify that the expenses listed above qualify as expenses under Section 129, Internal Revenue Code. Statement of Certification: I certify that I have provided care for to. My charge for this service was. s child (children or dependent) from Name and Address of Provider Provider s Signature Tax ID or SS# Please return this form to TML MultiState IEBP. Rev TML MultiState IEBP Page 62 of 71

63 PO Box Austin, Texas Fax: (512) Section 125 Flex Unreimbursed Reimbursement Form - Standard Plan Standard Plan Plan Year: Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new Description of Eligible Expense Incurred Total Amount of Bill Amount paid by any Plan Amount to be Reimbursed Expense for: (Name) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL $ $ $ AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws. I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have thirty-one (31) days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML MultiState Intergovernmental Employee Benefits Pool. I agree to only submit claims which qualify as expenses under Section 213, Internal Revenue Code. Please return this form to TML MultiState IEBP. Rev TML MultiState IEBP Page 63 of 71

64 Section 125 Flex Unreimbursed Reimbursement Form - Grace Period PO Box Austin, Texas Fax: (512) Grace Period Plan Plan Year: Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new Description of Eligible Expense Incurred Total Amount of Bill Amount paid by any Plan Amount to be Reimbursed Expense for: (Name) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL $ $ $ AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws with additional two (2) month-fifteen (15) day grace period. I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have thirty-one (31) days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML MultiState Intergovernmental Employee Benefits Pool. I agree to only submit claims which qualify as expenses under Section 213, Internal Revenue Code. Please return this form to TML MultiState IEBP. Rev TML MultiState IEBP Page 64 of 71

65 Section 125 Flex Unreimbursed Reimbursement Form - Carryover PO Box Austin, Texas Fax: (512) Carryover Plan Plan Year: Employer Name Employer Group # Employee Name Unique Identification #/Social Security # Street Address City State Zip Code Check here if new Mailing Address City State Zip Code Check here if new Description of Eligible Expense Incurred Total Amount of Bill Amount paid by any Plan Amount to be Reimbursed Expense for: (Name) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL $ $ $ AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws unless my employer has authorized a carryover pursuant to IRS Notice I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have thirty-one (31) days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML MultiState Intergovernmental Employee Benefits Pool. I agree to only submit claims which qualify as expenses under Section 213, Internal Revenue Code. Please return this form to TML MultiState IEBP. Rev TML MultiState IEBP Page 65 of 71

66 Section 125 Flex Recurring Expense Service Form PO Box Austin, Texas Fax: (512) INSTRUCTIONS: This form is used to request your Dependent Care Account or Transportation Account contributions be reimbursed to you on a per pay period basis. By completing this form you will not need to provide continuing documentation. Please complete all fields and include appropriate documentation stating your dependent will be attending throughout the year or specific time frames. All information must be completed by you & your Dependent Care provider to receive reimbursement. CLAIMS WILL NOT BE PROCESSED WITHOUT YOUR SIGNATURE AND THE PROVIDER'S SIGNATURE. A. Declaration of Services I request reimbursement for the below listed timeframe for qualified Dependent Care Services or Transportation Expenses I certify that the services will be provided between the following dates: to Start of Services (MM/DD/YY) End of Services (MM/DD/YY) I have included signed copies of the independent provider's charges, which will include the total amount of $ for the dates provided above. Total Amount of Services NOTE: If you have any changes during the dates referenced above, please notify TML MultiState IEBP at (800) or fax (512) B. Participant Information Name of Participant Unique Identification #/Social Security # Address: Street City State Zip Preferred Contact Phone # Name of Dependent C. Care Provider Information Name of Dependent Care/Transportation Expense Provider Address: Street City State Zip Federal Tax ID D. Signatures Authorized Signature of Provider Participant Signature PLEASE NOTE: Your total reimbursement amount will be calculated per the amount you have elected for the year based on the amount of payrolls that occur throughout the plan year. For questions regarding your maximum contribution amount, please contact TML MultiState IEBP at (800) or fax (512) Please return this form to TML MultiState IEBP. Rev TML MultiState IEBP Page 66 of 71

67 Section 125 Direct Deposit Authorization Agreement As a service of TML MultiState Intergovernmental Employee Benefits Pool (IEBP), we are offering you the opportunity to have the following claim payments deposited via electronic direct deposit into your bank account: Flexible Spending Arrangement (Section 125) Health Reimbursement Arrangement (HRA) When you agree to allow an automatic funds transfer (direct deposit) into your bank account, the permission to do so will remain in effect until you notify IEBP that you are removing that permission. If you are interested in taking advantage of this opportunity, please complete and return this form with a voided check and mail to: TML MultiState IEBP Accounting P. O. Box Austin, TX If you have any questions regarding this form, please contact Kathie Miller at Please Print As a duly authorized signatory of the account number listed below I, the undersigned, authorize IEBP to initiate credit entries through Chase Bank Austin or other transaction facilitating entities to my account, as indicated below and located at the contracted depository named below. Bank Name: Type of Account: Checking Savings Attach a voided check for the account or provide the following: ABA (Bank) Routing Number: (9 characters, normally located on bottom of check next to Account Number) Account Number: This authority is to remain in full force and effect until IEBP has received written notification from an authorized signatory of the account in such a time and in such a manner as to afford IEBP reasonable opportunity to act upon said notification. Employee Name Employee Unique Identification #/Social Security # Employer Name Employer Group Number Signature Preferred Contact Phone Number Rev TML MultiState IEBP Page 67 of 71