PEEHIP provides the most common forms needed during your career and retirement online.
For greater convenience, many of the functions achieved by the forms below can be done instantly online via our Member Online Services (MOS) website. You may also request these forms from Member Services.
- Southland Benefit Solutions Vision Claim Form
- Southland Benefit Solutions Dental Claim Form
- Southland Benefit Solutions Indemnity and Cancer Claim Form
- MedImpact Prescription Drug Claim Form
- MedImpact Prior Authorization Request Form
- Hospital Medical Claim Form - Group #14000 and #61000
- Flexible Spending Accounts Enrollment Application
- Flexible Spending Accounts Status Change
- Flexible Spending Accounts Direct Deposit Form
- Healthcare Flexible Spending Account Reimbursement Form HealthEquity
- Dependent Care Reimbursement Account Reimbursement Form HealthEquity
- Orthodontia Reimbursement Form