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)
- Personal Plans
- Time Off Programs
- Tuition Assistance
Flexible Spending Accounts (FSA)
- Forms (from Discovery Benefits)
- FSA Reimbursement Form (To ensure you have the most current form, we encourage you to download FSA forms from Discovery Benefits instead of using this copy.)
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Benefit Change and Benefits Enrollment Form (Qualifying/Life Event Change)
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Benefit Change Request Packet for Travelers (Qualifying/Life Event Change)
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Common Law Affidavit (Colorado Only)
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Coordination of Benefits (Online preferred)
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Coordination of Benefits (Print)
- Authorization To Use Or Disclose Protected Health Information
- Case Management Maternity Registration Form
- Medical Services Reimbursement Form (Use for Medical and Dental)
- 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
- 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 Web site (Intranet).
To obtain printable Family Medical Leave Certification, Family Medical Leave Request, or Authorization for PHI forms, please select the appropriate link below.
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I have contacted ABSENT8 |
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I have not contacted ABSENT8 |
Tuition Assistance
Current employees can find the Policy and Procedure and forms for Banner's tuition assistance on the Employee Web site (intranet, keyword search: Tuition Assistance).
