Benefit Forms

Below are forms related to Banner Health benefits that you may need from time to time.  If you do not see the form you need or have questions about any of the forms below, please contact your local Human Resources department for assistance.

Benefits Forms: 

• Flexible Spending Accounts (FSA)
• General Benefits Forms
• Health Plans (Dental, Medical, Pharmacy, Vision)
• Time Off Programs
• Tuition Assistance

Flexible Spending Accounts (FSA)

• To ensure you have the most current form, we encourage you to download FSA forms from Discovery Benefits.

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General Benefits Forms

• Benefits Enrollment and Change Form (Qualifying Event)
• Benefits Enrollment and Change Form for Travelers (Qualifying Event)
• Common Law Affidavit (Colorado Only)
• Coordination of Benefits (Online preferred)
• Coordination of Benefits (Print)
• PCP Biometrics Screening Form

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Health Plans

• Authorization To Use Or Disclose Protected Health Information
• Behavioral Health Non-Network Claim Form
• Case Management Maternity Registration Form
• Medical/Dental Services Reimbursement Form
• Member Appeal Guidelines 
• Pharmacy Claim Form
• Pre-Authorization Form for Prescriptions
• Referral Form (To be filled out by your Primary Care Physician)
• Transition of Care Form
• Vision Out-of-Network Claim Form

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Time Off Programs

• Assignment of Authorized Representative
• PTO Donation (Of Earned Hours)
• PTO Donation (Recipient Application)
• Return to Work Employee Request Form
• Workers' Compensation - To report a work related illness or injury, complete an accident injury report form online through the Employee Website.

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Tuition Assistance

Current employees can find the Policy and Procedure and forms for Banner's tuition assistance on the Employee Website, keyword search: Tuition Assistance.

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