AMO Medical Plan Forms

Coordination of Benefits (COB):

• Medical Plan Permanent Data and COB
• Medical Plan Affidavit for Dependent Child
• Medical Plan Permanent Data and 2013 Affidavit of Pensioners Medical Benefits Earnings Limitation and COB

Application for Benefits:

• Medical Plan Application for Benefits
• Foreign Medical Claim Form

Scholarship Applications:

• Medical Plan Application for Prepaid Scholarship Benefit
• Medical Plan Application for Scholarship Benefit

Protected Health Information (PHI) Authorization Forms:

• Medical Plan Authorization for Disclosure of PHI
• Medical Plan Authorization for Disclosure of PHI for Pre-Employment Purposes
• Medical Plan Authorization for Disclosure of PHI for Medical Center
• Medical Plan Cancellation of Authorization for Disclosure of PHI

Disability Applications:

• Medical Plan Application for Sickness and Accident Disability Benefit
• Medical Plan Claim for Total and Permanent Disability

Medical Plan Beneficiary Designation:

• Medical Plan Beneficiary Designation