Insurance Provider Claim Forms
Reimbursement FormsIndependence Blue Cross Out-of-Network Claim Formsare available by logging in to your account atwww.ibxpress.com and selecting the Resource Centertab at the top of the page.Delta Dental Fillable Claim Form: https://www.deltadentalins.com/forms/claimform-enterprise.pdfVBA Non-Participating Provider Claim Form:
Vision Reimbursement (all eligible employees)BAS Healthcare Reimbursement (flexible spending)BAS Dependent Care Reimbursement Form (flexible spending)Influenza Vaccine Reimbursement Form (Independence Blue Cross)
Mutual of Omaha Claim and Conversion FormsGroup Term Life/Voluntary Life Beneficiary Form - Mutual of Omaha (return to Benefits Coordinator)PSERS Nomination of Beneficiaries (submit to PSERS)Disability claim forms have been customized to include the district's group number information and you may elect to submit your claim directly to Mutual of Omaha without obtaining the Employer Statement. Mutual will contact the Benefits Coordinator directly for employer information.Short-Term Disability Claim Form (for those purchasing voluntary coverage)If you are leaving service with RTSD and want to take your current life/accident/disability insurance with you, complete the appropriate conversion form/s from the selections below.