Forms & Notices – Cuyahoga County

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Home / Benefit Forms & Notices

Benefit Forms & Notices

Benefit Forms

Affidavit of Current Marriage Form

Benefits Enrollment Form

Benefits Office Change (BOC) Form

CVS Caremark Mail Order Form

CVS Caremark Reimbursement Form

Glossary of Terms

MedMutual Life Beneficiary Designation

MedMutual Life Evidence of Insurability

MetroHealth Mail Order Form

RTA Payroll Deduction Form

VSP Member Reimbursement Form

Parking Claim Form

Important Employee Notices

Children’s Health Insurance Program (CHIP)

Genetic Information & Non Disclosure (GINA)

HIPAA Notice of Privacy Rights

HIPAA Notice Special Enrollment Rights

Initial COBRA Notice

Skyway - MetroHealth Select Name Change

Medicare Part D Notice of Credible Coverage

New Health Insurance Marketplace Coverage

Newborns’ and Mothers’ Health Protection Act

Uniformed Services Employment and Reemployment Rights Act (USERRA)

Woman’s Health and Cancer Right

Voluntary Benefits Claim Forms

Accident Claim Form

Additional Sickness Rider Claim Form

Cancer & Critical Illness Claim Form

Caregiver Benefit Claim Form

Disability Continuance Claim Form

Healthy Living Rider Claim Form

Initial Disability Claim Form

Pregnancy Disability Claim Form

Specified Illness Rider Claim Form

Cuyahoga County Benefits