Forms for Plan Members

J.P. Farley offers these forms for plan participants to utilize in accessing their benefit plan. The benefit plan 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
Supply additional information in regards to a claim for a possible accident or injury.

Coordination of Benefits Form
Provide J.P. Farley with information regarding other health insurance or plan coverage you or your dependents may have.

Dental Claim Form
Your dental provider will usually submit claims on your behalf directly to J.P. Farley. Use this form if you need to submit a dental claim to your health plan yourself.

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
Submit a claim for FSA reimbursement. Dependent care or other flexible spending account eligible expenses. Learn more about Flexible Savings Accounts.

Health History Statement Questionnaire
Employees may be asked to complete this form by their employer as part of the process of becoming covered by the health plan. The form MUST be printed, signed and returned to J.P. Farley as directed by the employer plan sponsor. Note: The form has fields that can be typed in, but employees must use the “save as” feature if they wish.

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 issues 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.

Medical Claim Form
Providers usually submit claims on your behalf directly to J.P. Farley. You may use this form if you need to submit a medical claim to your health plan yourself.

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.

Uniform Glossary
This glossary of terms is published by the Department of Labor (DOL) as outlined by recent health care reform laws. It is required to be the same for every health plan, regardless of the plan administrator, insurer, etc. As noted on the document, this glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs.

Vision Claim Form
Use this form if you need to submit a vision claim to J.P. Farley.

Wellness and/or Alternative Benefit Reimbursement Form(s)
If your employer offers a wellness or alternative medical treatment reimbursement arrangement you will find your custom benefit form is available within the website portal (after website registration) or in some cases from your employer.

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