Self Pay Portal

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Forms & Documents

All the documents and forms below are in PDF format, which can be viewed, downloaded and printed from virtually any computer or mobile device. Note that many of the PDF forms can be filled out electronically before printing for your convenience. If you cannot access or print a form or document, send us an e-mail request and we’ll be glad to mail a printed copy to your home address.

Important Documentation Required

For some forms, you may need to provide additional documentation, such as a provider’s receipt, additional claim form, or a marriage or birth certificate.

If you fill out the  Dependent Addition Request Form, you must enclose:

  • A certified state or county copy of your marriage certificate if you are adding a spouse, or
  • A certified state or county copy of the birth certificate if you are adding a child.

Please note:

  • A certified copy is a copy from the state or county in which the marriage or birth occurred. It must have the “raised seal”.
  • If you send originals, they will be copied and returned to you.
  • Hospital and church records are not acceptable.

Once you complete the Form, print it out and send the required documentation to the Fund Office.

Sending Forms to the Fund Office

When you complete, print, and sign a form, you can either scan and email or mail the form (and any required documentation, if necessary) to the Fund Office.