Some of the files below are PDF or MS Word files which require the free Adobe Reader and Word Viewer.
On this page:
- Health Benefits (for active employees & non-Medicare retirees)
- Health Benefits (for Medicare retirees)
- Dental Benefits
- Vision Benefits
- MaineSaves 457b
- Flexible Spending Accounts
- Health Credit Premium Program
- Retired Law Enforcement and Fire Fighter Subsidy Program
- Wellness Programs
- Other
Health Benefits (for active employees and non-Medicare retirees)
- Application Form (PDF) and Instructions (PDF) To enroll, add/delete members, address change, etc. Please note, incomplete forms will be returned.
- Employee Election to Cancel Health Insurance Form (PDF)
- Retiree Health Insurance Enrollment Form (PDF)
- Certification for Future Enrollment Form (PDF)
Health Benefits (for Medicare retirees)
- Retiree Health Insurance Enrollment Form (PDF)
- Certification for Future Enrollment Form (PDF)
- 2020 Application Form (PDF)
- 2019 Application Form (PDF)
- Prescription Drug Claim Form (PDF)
- Pharmacy Mail Order Form (PDF)
Dental Benefits
- Application Form (PDF) and Instructions (PDF) To enroll, add/delete members, address change, etc. Please note, incomplete forms will be returned.
- Claim Form (PDF)
Vision Benefits
- Application Form (PDF) and Instructions (PDF) To enroll, add/delete members, address change, etc. Please note, incomplete forms will be returned.
- Blue View Vision Claim Form (PDF) - To file a claim for services provided out of network
- EFT Form (MS-Word) - To sign up for automatic premium payment from your bank account
- Provider Recruitment Request Form (MS-Word)
MaineSaves 457b
(voluntary retirement savings)
- Visit our website or contact a local representative.
Flexible Spending Accounts
- 2019 Enrollment Form (PDF)
- Change in Status Form (PDF) - (For qualifying life events)
- Navia Health Care and Day Care FSA Forms
Health Credit Premium Program
- Health Credit Appeal Form - appeals deadline August 9, 2019
Retired Law Enforcement and Fire Fighter Subsidy Program
(County & Municipal employees only)
- Employee Enrollment Application Form (MS-Word)
- City of Portland Retirees Application to Determine Eligibility Form (MS-Word)
- Retiree Application to Determine Eligibility Form (MS-Word)
- Employee Withdrawal Form (MS-Word)
For Employees:
Wellness Programs
- Gym Membership Reimbursement Request Form (MS-Word)
- Gym Attendance Verification Worksheet (MS-Word)
- Wise & Well Nomination Form (PDF)
- On-Site Wellness Center Application Form (pdf)
- On-Site Wellness Center Waiver (pdf)
- On-Site Wellness Center Compliance Form (pdf)
- On-Site Wellness Center Medical Clearance Form (pdf) All retirees and their spouses must include a Medical Clearance Form and must have an initial consultation with a fitness specialist before utilizing the facility. Some employees and their spouses may also be required to provide a Medical Clearance Form depending on the health history provided on the Wellness Center Member Application Form.