Claims Forms

Medical

• CareFirst - Health Benefits Claim (For MD, DC and Northern Virginia service area)
• CareFirst - Health Benefits Claim (Out of Area) (For all other service areas)

Dental

• Aetna - Dental Benefits Request (for pretreatment of claim)
• Aetna - Dental Claim

Prescription Drugs

• Express Scripts – Mail Pharmacy Service (form not available online), please call HR Benefits Processing at 571-423-3200, option 3
• Express Scripts – Prescription Drug Claim
• Express Scripts – Prior Authorization Medication Request

Vision

• UnitedHealthcare Vision Out-of-Network Claim Form

Flexible Spending Accounts

• Reimbursement Claim
• Information about Reimbursements Claim
• Letter of Medical Need Claim
• Over the Counter Expenses
• 2009 Reimbursement Schedule  
• 2010 Reimbursement Schedule