Forms and information

Accident form
Appeal request form
Authorization for release of protected health information (PHI)
Disenrollment form
Eligibility extension changes (November 2020)
- Partial Self-Pay
- Full Self-Pay
- Retiree Self-Pay
- Super Saver
- Community resources
  - Medicaid information (November 2020)
  - Southern Nevada Medicaid plans comparison (November 2020)
  - Federally Qualified Health Centers in Southern Nevada (November 2020)
  - Nevada food banks (November 2020)
Life insurance beneficiary form
Loss of time (LOT) form and checklist
Medical/vision claim form
Medicare Part D notice
Open enrollment form
Open enrollment packet
Participant Guide
Private health survey
Retiree enrollment application
Self-pay
Summary Annual Report (SAR)
Summary of Benefits and Coverage (SBC)
Womenʼs Breast Cancer Annual Notice