Medical Claim Forms
Standard Option Dental Claim Forms
AETNA Dental Claims
Vision Claim Forms
Medco by Mail Order Form
Prescription Drug Reimbursement Form
Coordination of Benefits Form
Payroll Allotment Form 299
NOTE: Employees of FBI, USSS, DEA, ATF, CBP, CIS, and ICE must complete the SAMBA Payroll Allotment Form 299.
Direct Debit Form
All other agencies must complete the Direct Debit application.
CIGNA Provider Nomination Form
Beneficiary Designation Form (For SAMBA Term Life Plan only)
Authorized Representative Form
Authorized Use & Disclosure Form
Revocation Authorization Form
