AMO Medical Plan Forms

Coordination of Benefits (COB):

• Coordination of Benefits for Dependent Spouse and Dependent Children
• Affidavit of Support for Dependent Student
• Affidavit of Support for Each Child Between the Age of 19 and 26 Listed as a Dependent
• Dependent Parent's Medical Benefits Affidavit of Support, Earnings Limitation and Coordination of Benefits
• Affidavit of Pensioner's Medical Benefits Earnings Limitation and Coordination of Benefits
• Affidavit of Support for a Stepchild or Child Under Legal Guardianship/Custody
• Change of Address Form

Application for Benefits:

• Application for Benefits

Scholarship Applications:

• Application for Prepaid Scholarship Benefit (Maritime Academy)
• Application for Scholarship Benefit

Protected Health Information (PHI) Authorization Forms:

• Authorization for Use or Disclosure of Protected Health Information (PHI)
• Authorization for Use or Disclosure of PHI for Pre-Employment Purposes (Medical Center)
• Authorization for Use or Disclosure of PHI (Medical Center)
• Cancellation of Authorization for Disclosure of Protected Health Information (PHI)

Disability Applications:

• Application for Sickness and Accident Disability Benefit (Short-term Disability)
• Claim for Total and Permanent Disability

Medical Plan Beneficiary Designation:

• Beneficiary Designation form for Death, Accidental Death and Dismemberment Benefit