Waiver of Medical Coverage:

LMU offers employees optional medical coverage for themselves and their dependents. Although LMU subsidizes the cost of the medical coverage, no employee is required to enroll in any LMU medical plan.

The purpose of this form is to waive medical coverage and to advise you of possible future medical plan enrollment restrictions.

• Waiver of Medical Coverage Form 

 Anthem Blue Cross Forms:

• Anthem Blue Cross Member Claim Form
• Anthem Blue Cross Prescription Claim Form
• Anthem Blue Cross Prescription Mail Order Application
• Anthem Blue Cross Drug Formulary

  (most updated formulary available on the website www.anthem.com/ca)

• Anthem Blue Cross Prior Authorization Clarinex Form
• Anthem BlueCross Prior Authorization Antihistamines Form
  

Carpool Form:

• Questionnaire

CIGNA Forms:

• CIGNA Dental PPO/Indemnity Claim Form

CONEXIS Forms:

• CONEXIS Medical Reimbursement Form
• CONEXIS Dependent Care Reimbursement Form
• CONEXIS Change Verification Form, Medical Account
• CONEXIS Change Verification Form, Dependent Care Account
• CONEXIS Direct Deposit Form
• CONEXIS Over the Counter Drug List

HIPAA Forms:

• Blue Cross HIPAA Authorization Form
• LMU HIPAA Privacy Authorization Form

Lactation Room Reservation:

• Reservation Form
• Please save a copy of this PDF to your local drive then complete and submit via e-mail.

MetLife Forms:

• Spouse Waiver of Beneficiary  
• Statement of Health
• Election of Portability

• Out of Network Reimbursement

 WageWorks FSA Forms:

• Claim Form - Health Care
• Claim Form - Dependent Care
• Eligible Expenses - Health Care
• Eligible Expenses - Dependent Care

There are separate files for each page of the two-sided forms so you can print a double-sided sheet. These forms are also in .pdf format, so if you don't have the Acrobat Reader, follow the link to download the program.