Office of Employee Benefits Forms and Office Locations – Government Agency in Rhode Island

All 11 forms

Form Title	Topics
CVS Caremark Mail Order
CVS Caremark Rx Claim
Medicare Exchange Eligibility
Pre-65 Retiree Health Coverage Election Form (Judges and Legislators)
Pre-65 Retiree Health Coverage Election Form (State Employees, Public School Teachers, and Disabled Retirees – Date of Retirement BEFORE 10/1/08)
Pre-65 Retiree Health Coverage Election Form (State Employees, Public School Teachers, and Disabled Retirees - Date of Retirement ON OR AFTER 10/1/08)
Retiree Health Coverage Cancellation
RIPTA Payroll Deduction
The Hartford Beneficiary Designation
Unforeseeable Emergency Withdrawal Request
VSP Out-of-Network Reimbursement Form

Office of Employee Benefits