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Accident Insurance Program Enrollment Form
To be completed by the worker and employer representative to enroll or change participation in the Accident Insurance Program (AIP).
Account Option Election Form
For the Concordia Retirement Plan (CRP).
Annual Open Enrollment Form
To be completed by a worker during an annual open enrollment period who desires enrollment in the Concordia Health Plan for him/herself, a spouse, or dependent children. NOTE: This Form is only for workers at employers who offer one CHP Option. Workers at employers who offer 2 or 3 CHP Options for worker selection should request the customized Worker Choice Election / Open Enrollment Application Form (combined into one form) from their employer.
Beneficiary Designation Form - CDSP/AIP - NOTE: This Form is for Active Workers.
To be completed by the member to report a beneficiary for the death benefits payable from the Concordia Disability and Survivor Plan and/or Accident Insurance Program.
Beneficiary Designation Form - CRP for RCA/SRA benefits - NOTE: This form is for Active Workers. To be completed by the active member to report a beneficiary for their Retirement Cash Account and Supplemental Retirement Account benefits.
Beneficiary Designation Form - CRP- NOTE: This Form is for Retired Members.
To be completed by the retired member or surviving spouse of a retired member to report a beneficiary for the death benefits payable from the Concordia Retirement Plan. This form can also be completed by a vested terminated worker that has deferred his/her Supplemental Retirement Account (SRA) payment from the Concordia Retirement Plan.
Blue Cross Blue Shield Preventive Care Guidelines
Blue Cross Blue Shield Medical Claim Form
Blue Cross Blue Shield International Claim Form
Certification of Non-Participation of Ineligible Workers
Change of Contact Information
Cigna Behavioral Health Claim Form
To be used to submit a claim for out-of-network services.
Cigna Dental Claim Form
Cigna Dentist Nomination Form
Cigna Prescription Drug List 2014
Cigna Medical Claim Form
Cigna Preventive Care Guidelines
Concordia Health Plan Enrollment Form (for retired members only)
To be completed by a retired member who previously declined CHP coverage for him/herself and/or eligible dependents
Declaration of Hours Form
To be completed by the employer to elect which definition of "full-time" to apply to its workers in order to determine Concordia Health Plan (CHP) eligibility.
EBSO CRSP Automatic Annual Election
EBSO CRSP Change to Automatic Election
Electronic Funds Transfer (EFT)
To be completed by the member (or surviving spouse) to set up electronic direct deposit of monthly retirement, disability, and survivor benefits.
Employer Contribution Election Form - Concordia Retirement Savings Plan
To be completed by a newly hired worker, including a worker who has transferred. This form must be completed by both the worker and an employer representative. NOTE: Employers in the Concordia Health Plan (CHP) are responsible for providing the 2014 Summary of Benefits and Coverage (SBC) applicable to the employer's CHP Option(s) to any newly hired workers who are eligible to enroll in the CHP. To obtain the SBCs, click here.
Enrollment Form (for newborns only)
Express Scripts Preferred Drug List 2014 (Non-Medicare)
Express Scripts Formulary 2014 (Medicare)
Express Scripts Mail Order Claim Form
Express Scripts Short-Term Prescription Claim Form (non-Medicare members)
This form can also be used to file claims for prescriptions purchased outside the United States.
Express Scripts Short-Term Prescription Claim Form—Medicare Members
HIPAA Authorization Form and Instructions
Authorization form for use or disclosure of protected health information. See HIPAA Compliance.
HIPAA Privacy Notice
Michelle's Law Application
For Concordia Health Plan coverage of an enrolled dependent during a medically necessary leave of absence from school.
Nomination of Benefit Plan Representative
To be completed by a worker who wants to designate a Representative to obtain information from Concordia Plan Services on the worker's behalf for the following Concordia Plans: CRP, CDSP, CRSP, PPPT, and AIP. If a worker wants to designate a Representative to obtain information on his/her behalf for the CHP, a different form, the Authorization Form and Instructions - Health Insurance Portability & Accountability Act (HIPAA)" form, must be completed.
Probationary Period Certification Form
To be completed by an employer wanting to establish a probationary period for delayed enrollment of new employees in the Concordia Plans.
Provider Preventive Care Notice
To be printed by workers in the CHP and taken along on preventive care doctor visits to explain the preventive care billing process.
Reason for Non-Enrollment in the Concordia Health Plan
To be completed by a worker when declining enrollment in the Concordia Health Plan for him/herself, the spouse, or dependent children.
Record of Ineligible Worker
To be completed by part-time workers and temporary workers who are not eligible to participate in the Concordia Plans.
Request for Membership Change
To be completed by the member and employer representative to report changes which affect Plans' membership, such as marriage, divorce, new dependent (spouse or child), removal of dependent, change in retirement plan class, and enrollment or change in Accident Insurance Program.
Request for Taxpayer Idenfication Number and Certification
2014 Salary Deferral Agreement
To be completed by a worker to begin or adjust payroll deductions for CRSP. Qualified workers may elect to contribute above the yearly maximum amount allowable by completing the "Authorization for Catch-up Contribution" section. This form should be
turned in to the payroll department or congregational treasurer.
SelectAccount Medical Expense Reimbursement Claim Form
Special Enrollment Application Form
To be completed by a worker who previously declined CHP coverage for him/herself and/or eligible dependents. Special enrollment eligibility requirements will apply.
VSP Out-of-Network Claim Form
Worker Change Report Forms
To be completed by an employer representative or worker to report changes in a worker's Plan membership.
Worker Status Verification
To be completed when a worker returns to work either part-time or full-time after a disability.