Benefit Forms

MCEBP Members

• Accident/Injury Questionnaire
• Authorization To Release Protected Health Information
• Flex - Dependent Care Reimbursement Form
• Flex - Direct Deposit Authorization Form
• Flex - Letter of Medical Necessity Form
• Flex - Medical Expense Reimbursement Form
• Self Submittal Claim
• Yearly Update Request Form

Providers

• Pre-Authorization Request Form
• Precertification - Inpatient Stay Form