• Medical Claim Forms

    Medical claims on and after 7-1-2025

    Blue Shield of CA - Out of network claim form.

    Connect team customer service: 888-499-5532

    Click here for additional Blue Shield details.

  • Dental Claim Form

    The Dental Claim form applies to the Dental PPO plan Only. If your dentist is an out-of-network provider and does not submit your service to the insurance company, please complete form to receive your dental benefit.


    Dental Claim Form


    Directions on Filing Dental Claim Form


    Phone: 800-765-6003

    Website: deltadentalins.com

    PPO Group number: 00511



  • Vision VSP Claim Form

    Submit a claim with VSP if you visit an Out-of-Network provider.


    Directions to filing a VSP claim


    Phone: 800-877-7195

    Website: www.vsp.com

    Group number: 30058404

  • FSA Tax Spending Claim Form

    If you did not use your FSA debit card or if HealthEquity requires documentation for the debit card you used, please submit documentation or claim to your FSA account.


    Click here to visit the FSA page for additional details and resources.