AlaskaCare Employee Forms

Claim Forms

Health Benefits

Health Benefits Claim Form [PDF 230K]

Use this form to file medical, vision, dental, and audio services manually. It is not necessary to file manual claims if your provider bills for you.

Health Flexible Spending Account (HFSA)

HFSA Reimbursement Form [PDF 119K]

Submit this form with itemized statements or receipts and an explanation of benefits form

HFSA Over-The-Counter (OTC) Reimbursement

HFSA Claim Form For OTC Reimbursement [PDF 108K]

Complete and submit form with itemized statements or receipts and an explanation of benefits form

Managed Care Vision Out-of-Network VSP

Managed Care Vision Out-of-Network VSP Reimbursement Form [PDF 129K]

Submit this form with itemized receipts when enrolled in the Managed Care Vision if you receive vision services from a non-participating provider

Prescription Drug Self-Pay Reimbursement form

Prescription Drug (member self-pay) Reimbursement form [PDF 249K]

Submit this form for your prescription benefit program member self-payment reimbursement