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Nevada Public Employees' Benefits Program
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Eligibility Forms for All Plans
Insurance Marketplace Coverage Options for Eligible New Hires PY24
Insurance Marketplace Coverage Options for Ineligible New Hires PY24
Certification of Disabled Dependent Child
Guardianship to Age 26 Certification Form
Release of Information Authorization
Retiree Benefit Enrollment and Change Form
Years of Service Form
Benefit Enrollment and Change Form Unsubsidized
Travel Pre-Authorization Form
Travel Reimbursement Form
Appeal Forms
External Review Request Form
Internal Claim Appeal Request Level 2
Expedited Review Form
Physician Certification of Experimental/Investigational Denials Form
Consumer Driven Health Plan (PPO) Forms
Express Scripts RX Reimbursement Claim Form
Express Scripts RX Mail Order Delivery Form
UMR Medical Claim Form
Obesity Care Management Initial Evaluation Form
Diabetes Care Management Form
HSA Designation of Beneficiary Form
HSA Direct Transfer Request Form
HSA Application and Eligibility Form
HRA Reimbursement Request Form
Transition of Care & Continuity of Care Form
Flexible Spending Account Forms
Flexible Spending Enrollment Form
Health Care and Dependent Care Reimbursement Request Form
Direct Deposit Authorization Form
Health Plan of Nevada (HMO) Forms
Non-Plan Provider Claim Form
Optum Pharmacy Mail Order Form
Optum Pharmacy Reimbursement Form
HRA Reimbursement Request Form
Low Deductible Plan (PPO) & Exclusive Provider Organization Plan (EPO) Forms:
Express Scripts RX Reimbursement Claim Form
Express Scripts RX Mail Order Delivery Form
UMR Medical Claim Form
HRA Reimbursement Request Form
Transition of Care & Continuity of Care Form
Basic Life Insurance Forms:
United Healthcare is the plan administrator for the basic life insurance policy provided to eligible active and retired members.
For basic life insurance death claims where the participant was deceased prior to 7/1/2022 contact The Standard—Customer Service: 1-888-288-1270.
Accelerated Death Life Insurance Benefit
Life Claim Form
Waiver of Premium Form
The Standard Insurance Forms for Voluntary Life Insurance
Group Life Conversion Form
Group Life Portability Form
Life Insurance Claim Form
PEBP Vaccine Clinic Consent Form
Informed Consent for Immunization with Inactivated & Live Vaccines
E-PEBP Portal
Frequently Asked Questions (FAQs)
Health and Wellness
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