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Flexible Spending Account Claim Form

• HSA Bank Flex Account Claim Form - Health Care FSA and Dependent Care FSA

Health Plan Claim Forms - At Home COVID-19 Tests

• For details about at-home COVID-19 testing and reimbursement, including a link to the reimbursement form, please visit .

Health Plan Claim Forms - Dental

• BCBSM member dental application for payment consideration form

Health Plan Claim Forms - Medical

• BCBSM PPO medical reimbursement claim form
• BCBSM PPO How to File Massage Therapy claims
• BCN HMO member reimbursement claim form

Health Plan Claim Forms - Prescriptions

• HMO/PPO prescription drug outside U.S. reimbursement claim form
• HMO/PPO prescription drug reimbursement claim form

Health Plan Claim Forms - Vision

• VSP member reimbursement form

Long-term Disability Forms

Complete Electronically

Below are the forms necessary to apply for Long Term Disability benefits. You will need to complete the following sections:

• Employee Statement (Pages 2 to 5)
• Authorization to Obtain and Release Information (Pages 6 to 7)
• Authorization to Obtain Psychotherapy Notes (if applicable) (Page 8)
• Part A of the Physician Statement (Page 13)

Your physician(s) should complete Part B of the Physician Statement and mail the complete directly to The Standard. Your employer should complete the Employer Statement. Please leave both sections blank.

Every space on every form that you are to complete should be filled to avoid delay in processing your application. If a section does not apply, or information is not available, write "NA" in the space. Please remember to include your sign, date and include your policy number; 754589, where necessary. Additional instructions for those sections can be found below or on the first page of the claim packet.

• É«É«À² LTD Claim Packet

Print to Complete

Below are the forms necessary to apply for Long Term Disability benefits. Every space on every form should be filled to avoid delay in processing your application. If a section does not apply, or information is not available, write "NA" in the space.

• É«É«À² LTD Authorizations -  Please sign and date the Authorization to Obtain and Release Information and attach it to the Employee's Statement. If you have seen or been treated by a Psychiatrist, Psychotherapist, Psychologist, Clinical Social Worker (MSW, MCSW, etc.) or any other provider of treatment for a mental condition, please sign and return the Authorization to Obtain and Release Information and the Authorization to Obtain and Release Psychotherapy Notes.   
• É«É«À² LTD Employee Statement - Be sure to use the appropriate section for injury, sickness or pregnancy. If a question does not apply to you write "NA". Use an additional page, if necessary to give full and complete answers. Also attach copies of any Social Security, Public Employees Retirement System, Workers' Compensation or other benefit determinations you have received. If you have applied for any other benefits but have not yet received them, please send a copy of the application receipt. If you are unable to make copies of these documents please send the originals. The Standard will photocopy and return them to you promptly. Remember to sign and date your statement.
• É«É«À² LTD Physician Statement - Part A should be completed by you. Part B should be completed by your physician. If you have seen more than one physician for your disability, a statement should be completed by each physician. Your physician(s) should mail the completed form directly to The Standard.

Please remember to include your sign, date and include your policy number; 754589, where necessary. You are responsible for making sure all required forms are competed and return to The Standard. If you have any questions please contact Human Resources or call The Standard's customer service line at (800)-368-1135.