Forms
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Forms
The links below will take you to explanations and printable versions of the forms you may need to complete in order to become a participant in MLH's benefit programs. Ask your Benefit Counselor if you have any questions about when to complete any of these forms. Forms are listed in alphabetical order.
You can use this form to request reimbursement of covered expenses associated with adopting a child. Please refer to the Adoption Assistance policy on the MLH Intranet for a list of covered expenses.
Use this form to submit claims directly to the Aetna DMO Plan.
Use this form to submit claims directly to the Aetna PPO. The Aetna PCP form is used to select a Primary Care Physician (PCP) under the Aetna HMO medical plan.
Used to submit a prescription plan claim directly to Aetna.
Use this form to submit claims directly to the Deltal Dental Plan
Use this form to submit your Dependent Care bills for reimbursement by SHPS.
Use this form to submit your eligible healthcare bills for reimbursement by SHPS.
Use this form to apply for Keystone HMO coverage
The life insurance beneficiary form is the form to elect your beneficiaries for your Life and AD&D Insurance. You may change your beneficiary at any time by completing a new Beneficiary Designation Form.
Complete this form and submit it to the Employee Pharmacy the first time you drop off a prescription to be filled for you or any of your dependents.
Complete this form and submit it to the Employee Pharmacy the first time you drop off a prescription to be filled for you or any of your dependents.
When you are approaching retirement, complete this form to apply for your pension benefits or ask for an estimate.
Use this form to submit claims directly to the Blue Cross Personal Choice PPO.
Please review the Qualifying Status Change Guidelines before completing the Qualifying Status Change Form. Contact your Benefits Counselor with any questions.
Full and part time employees may make changes to your benefit elections at open enrollment or within 30 days of the qualifying event to make a mid-year change. For additional information, contact your Benefits Counselor.
Complete this form to authorize MLH to make payroll deductions for the Retirement Savings Plan with MetLife, AmeriPrise & TIAA-CREF