AssureCare - Forms and Supplies

	Changing the Landscape of Healthcare Costs and Outcomes
New Directions In Healthcare	Greater Freedom of Choice - Substantial Savings

The following forms and supplies are available from our Corporate office.

*Expect 2-3 business days for shipping.

Selected forms are available below for immediate downloading in a PDF format. If you do not have the newest version of Acrobat Reader you can simply download it for free by clicking on the the icon below.

For questions call 1-800-328-0927.

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Company Name*

Your Name*

AssureCare Servicing Location*

Shipping Address*

City*

State*

ZIP*

Phone Number* ext.

* required for shipping

Group Number

Please check the items you would like and select a quantity.

If you prefer to immediately print out a form, simply click on the "Print Form" hyperlink directly to the right of the form you desire.

Group Enrollment Print Form

Weekly Disability

Change Request Print Form

(Status Update Form)

Vision Care Claim Print Form

Cobra Eligibility Notification Print Form

Cobra Envelope

Cobra Benefits Information Print Form

Personal Health Statement

Group Claim (Medical) Print Form

Group Claim Envelope

Dental Claim Print Form

Flexible Benefit Form

Flexible Spending

Flex Envelope

Second Surgical Opinion Print Form

Summary Plan Description

Please allow 2-3 weeks for delivery

Employee NurseLine Brochures

Employee Assistance Program Information

CareMark Prescription Mail Order

Additional CareMark RX Forms

Questions or Comments/Other Forms

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