J.P. Farley offers these forms for plan participants to utilize in accessing their benefit plan. The forms posted here are general forms. Your employer may have made arrangements to work with J.P. Farley to create customized forms for your particular health plan. Members may login to access any such custom forms or obtain a form from their employer's benefits department.
Accident Detail & Subrogation Form - This form is made available in order to supply additional information to J.P. Farley in regards to a claim for a possible accident or injury.
Coordination of Benefits Form - This form should be utilized to provide J.P. Farley with information regarding other health insurance or plan coverage you or your dependents may have.
Disability Form - Use this form to provide J.P. Farley with information regarding your short-term or long-term disability claim. There are three parts to this form, including a section for the employee to complete, a portion for the employer and a section for the employee's physician, all which must be completed in full to ensure timely processing of your disability claim.
Flexible Spending Account Reimbursement Form - This form should be used to submit a claim for FSA reimbursement. You may use this form for your health care, dependent care or other flexible spending account eligible expenses. Learn more about Flexible Savings Accounts.
HIPAA Designation of Authorized Representative Request Form - You have the right to request to have someone else to act on your behalf when resolving claims or customer service issue or when seeking benefit information from their plan. This form should be used to authorize an individual to act on your behalf until you notify the J.P. Farley Corporation to revoke the request. An example would be designating a power of attorney. Learn more about Managing Your HIPAA Protected Information.
Primary Care Physician Request Form - This form should be completed to declare a primary care physician for you and all of your dependents. The information will be held confidential and will be used only to verify the selection of your Primary Care Physician.
Website Registration Instructions - Plan participants are encouraged to register on our website for secure access to their benefits and plan information. These instructions will assist members in gaining access to their health information. Members who have been with J.P. Farley for some time, but have not registered on our new, updated online benefits portal will need to re-register in order to access their information and upgrade their account security.