SAMBA - FORMS

FORMS
Claim Forms Medical Claim Forms AETNA Dental Claims 2012 Vision Claim Forms 2011 Vision Claim Forms Medco by Mail Order Form Prescription Drug Reimbursement Form Medco Coordination of Benefits Form Payment Forms Payroll Allotment Form 299 NOTE: Employees of FBI, USSS, DEA, ATF, CBP, CIS, and ICE must complete the SAMBA Payroll Allotment Form 299. Direct Debit Form All other agencies must complete the Direct Debit application. Other Forms CIGNA Provider Nomination Form Beneficiary Designation Form (For SAMBA Term Life Plan only) Authorized Representative Form Authorized Use & Disclosure Form Revocation Authorization Form Child Age 22-26 Notification Form
These fillable forms are best viewed in Adobe Reader 9.2. Click on the link below to download a free copy.

FORMS