Forms & Information

Forms
Affirmation of Common Law Form (PDF)
Affirmation of Common Law Procedures (PDF)

CMS Data Collection for Section 111 Compliance (PDF)

Colonial Request for Service Form (PDF)
Coordination of Benefits Questionnaire (PDF)
Explanation of Benefits Sample (PDF)
HMA HIPAA Release Form (PDF)
HMA Enrollment form (PDF)
HMA Third Party Liability Questionnaire (PDF)
Medicare D Notice (PDF)
MetLife Plan Summary (PDF)
MetLife Beneficiary Designation Form (PDF)
  • Addendum - Primary Beneficiary (PDF)
  • Addendum - Contingent Beneficiary (PDF)
  • MetLife Life Claim Form (PDF)
    MetLife Accident Claim Form (PDF)
    Native Traditional Healing Procedures (PDF)
    Native Traditional Healing Form (PDF)
    Navajo Nation Employee Benefits Program Pamphlet (PDF)
    Navajo Nation Plan Document (PDF)
    QualSight Brochure (PDF)
    QualSight FAQs (PDF)
    QualSight Stuffer (PDF)
    Request for Out-Of-Pocket Reimbursement Form (PDF) - for all benefits
    Short-Term Disability Instruction Application (PDF)
    Short-Term Disability Report of Sick Leave Form (PDF)
    Short-Term Disability Preliminary Statement of Disability Form (PDF)
    Summary of Benefits Coverage (English) (PDF)
    Summary of Benefits Coverage (Navajo) (PDF)
    WellDyneRx Member Registration (PDF)
    WellDyneRx Preferred Drug List (PDF)
    WellDyneRx Prescription Delivery Service Registration (PDF)
    WellDyneRx Reimbursement Claim Form (PDF)

    Presentations
    Employee Benefits Presentation (PDF)

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