Important Forms

This is the Cash in Lieu of Insurance Form to be filled out in the event that you wish to opt out of the Peralta Medical and Dental Insurance plans and recieve cash in lieu of enrollment.

File size: 24 K

FSA Forms

Direct Deposit Form

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Want your reimbursements with the convenience of having your reimbursement checks directly deposited into your checking and/or savings account? Sign up for direct deposit now!

File size: 62 K

2010 FSA (Section 125) Enrollment Form

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This is the Flexible Spending Accounts (Section 125) Enrollment Form.

File size: 57 K

FSA (Section 125) Claim Form

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This is the FSA Claim Form.

File size: 573 K

Kaiser HMO Forms

Kaiser HMO - Emergency Claim Form

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This is the Kaiser HMO Emergency Claim Form. This form is to be used if you accessed emergency care while traveling outside of the Kaiser network.

File size: 101 K

Kaiser HMO Expense Reimbursement Form

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This is the Kaiser HMO Expense Reimbursement Form.

File size: 27 K

Kaiser HMO - Dependent Student Certification Form

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This form is to be completed at least once per year by the member and returned to Human Resources. The form applies to Dependent Student coverage under the Kasier HMO Plan.

File size: 24 K

CoreSource PPO Forms

CoreSource PPO Medical Claim Form

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This is the CoreSource PPO Medical Claim Form. You must complete claim forms and file claims to receive payment (Note, you MUST file your claims in a timely fashion, failure to file a claim in a timely fashion WILL result in the claim being denied and the entire claim will be your financial responsibility.)

File size: 31 K

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