Delta Dental of Ohio Claim Form
NOTE: If you seek treatment from a participating dentist, you do not need to print a claim form; the dentist will have a form and will submit it for you.
Benefit Enrollment/Change Form (ADM 4717) (exempt employees)
When you and your dependents become eligible for dental or vision coverage, complete this form and return it to your payroll office. See the Dental and Vision pages for more information.
Union Benefits Trust
Application for Disability Leave Benefits-Employee Statement (ADM 4310)
This form is used only for an initial filing of benefits.
Application for Disability Leave Benefits-Employer Statement (ADM 4312)
This is the employer's information and is to be attached to ADM 4310. This form is also used when the employee is requesting an extension of benefits.
Disability Agreement (ADM 4313)
This form is used when filing for disability as an advancement of Workers' Compensation.
Disability - Agency Disability Questionnaire
This form is to be completed by the employer and should accompany all initial mental health-related disability claims being filed with DAS Benefits Administrative Services for Disability.
Disability - Request for Appeal
Statement of Psychiatric Disability (ADM 4316)
This form is to be used when filing for disability benefits for mental/behavioral health disability. This should be used in addition to ADM 4310.
Supplemental Report for Disability Leave -Employee Statement (ADM 4311)
This form is to be used by the employee to request an extension of disability benefits.
Supplemental Report for Disability Leave-Employer Statement
This form is to be completed by the agency and accompany the employee's Supplement Report for disability leave benefits being submitted to DAS Benefits Administrative Services.
Work Capacity Form (ADM 4317)
This form is to be completed by the attending physician for use in transitional return to work. This may be used for either Worker's Compensation or Disability.
Verification Form (NOTE: This form has been replaced by the Union Benefits Trust Dental & Vision Enrollment form under the Dental/Vision section above.)
Affidavit of Common Law Marriage (ADM 4731)
This affidavit should be used to enroll a common law spouse for benefits.
Affidavit of Student Status (ADM 4729)
This affidavit is to be completed when an enrolled dependent turns 19, a dependent is being enrolled in coverage or the document is requested during the course of an audit.
Handicap Child Member Form
The required form may be obtained from your agency benefits specialist. After completing the form, submit it to DAS HRD HCM Benefits via fax at 614-728-3002 (a secure fax) or via email at email@example.com.
Minnesota Life Insurance Enrollment Form
This form is to be used by eligible, exempt employees who want to enroll in supplemental life insurance coverage for themselves, their spouse or their children. Once an employee is eligible for basic life insurance (after one year of continuous service), enrollment is automatic and does not require an enrollment form.
Minnesota Life Beneficiary Designation Form
This form is to be used by exempt employees who have basic and/or supplemental life insurance with Minnesota Life.
If an employee has both basic and supplemental life insurance, the most recent beneficiary designation on file with Minnesota Life will apply to both policies. Therefore, an employee cannot designate one beneficiary for one of the policies and a different beneficiary for the other policy.
Life Insurance (Basic) Continuation Form (ADM 4302) (for laid-off employees)
Benefit Enrollment and Change Form (ADM 4717)
Needed to initially enroll yourself and your dependents in the Ohio Med PPO. Also used to make changes throughout the year such as the addition of a newborn or adopted child, the removal of a dependent, changing from family to single coverage, etc. For more information, refer to the Pathways to myBenefits Open Enrollment edition.
OptumRx Mail Order Registration & Prescription Order Form
Use this form to register to use the OptumRx mail order program provided by OptumRx Home Delivery.
OptumRx Direct Member Reimbursement Form
Use this form to request reimbursement from OptumRx for unpaid prescription drug claims.
OptumRx Prescription Fax Form
The OptumRx Prescription Fax Form is a form that you can take to your physician's office during an office visit to have your physician fax your prescription to our mail service provider OptumRx Home Delivery. This form must be faxed directly from your physician's office in order to be valid.
Flexible Spending Accounts Materials
2017 Flexible Spending Accounts Reference Guide
Health Care Spending Accounts
2017 Health Care Spending Account Enrollment Form
HCSA Pay Me Back Claim Form
2017 FSA Health Care Spending Account Worksheet
FSA Change in Status Form
Dependent Care Spending Accounts
2017 Dependent Care Spending Account Enrollment Form
DCSA Pay Me Back Claim Form
2017 FSA Dependent Care Spending Account Worksheet
FSA Change in Status Form
Click here to return to the Flexible Spending Accounts web page.
Accident or Illness Report (ADM 4303)
This report should be completed if you are injured at work. For more details, see the Workers' Compensation web page.
Salary Continuation or Occupational Injury Leave Extension / Reactivation Request Form (ADM 4726)
Calendar of Wages Paid (ADM 4741)
This form is for agency use only. This form is used by the agency to report wages for lost time Workers' Compensation claims.
Salary Continuation/Occupational Injury Leave Hourly Payment Request Form
This form is to be used by an employee when requesting the use of Salary Continuation/Occupational Injury Leave on an hourly basis. This form is to be used only if the employee is in a transitional work program.
Salary Continuation and Occupational Injury Leave Appeal Form
Part-time Employment Calculation Report (ADM 4728)