Roger Hicks & Associates

Client Services & Forms

After enrollment is when you will really notice the difference between our agency and the competition. Roger Hicks & Associates Group Insurance, Inc. will serve as your ombudsman and advocate in the costly and confusing environment of group insurance. The Agency works for you, not for the third-party administrator and not for the reinsurance company. Roger Hicks and his associates will always be committed to your interest and to the interest of the insured, intervening in matters of contract, government regulation and mandates. We go that extra mile for the insured, representing the insured before insurance company claim determination committees, before insurance company medical directors, before peer review boards, at the State Insurance Department, and if necessary, in court, and all without any additional incidental charges.

We have a dedicated client service representative (CSR) whose primary responsibility is to service the needs of our clients. Our CSR will assist with new employee benefit meetings, keeping clients abreast of changes in benefit laws and legislation that may impact employers, assist with claim resolution, assist with benefit interpretation for employers and their employees, as well as prepare benefit packets, or any other assistance that you may require. Our CSR is your resource to use and we encourage our clients to do so.

Questions or Concerns? Simply e-mail us, be sure you include your name, the name of your employer, and an e-mail or phone number where we may contact you. We will be in touch with you for any other information we may need to assist you with your concern or question. We will get back to you with an answer as soon as we can.

In order to assist with your claim, we must have a signed release of protected health information. Please download and complete the attached form. Be sure to sign and date it and fax the form to us at 405.478.3636. We must have the original on file, so you will need to mail the original or allow our Client Services Representative pick it up from you. PHI FORM

Forms

We have attached the most commonly requested forms listed by insurance company below. Please submit all completed forms to our office via fax 405.478.3636 or mail PO Box 18169 , Oklahoma City , OK 73154 . If you have any questions or need help competing your form, or if you need a form that is not found below, please contact us.

Note: You will need Adobe Acrobat Reader to open these forms. If you do not have Adobe Acrobat Reader, you may download it here.

• BlueCross BlueShield of Oklahoma
• Delta Dental of Oklahoma
• Fort Dearborn Life
• Genworth (GE Financial)
• Hartford
• MetLife
• PacifiCare
• Principal
• SunLife
• Unicare
• United Healthcare

BlueCross BlueShield of Oklahoma

• BlueCross Enrollment Form
• BlueCross Declination Form
• BlueCross PPO Change Form
• BlueCross HMO Change Form
• BlueCross Medical Claim Form
• BlueCross Prescription Claim Form
• BlueCross Prescription Mail Order Form
• BlueCross PPO COBRA Election Form
• BlueCross HMO COBRA Election Form
• BlueCross HIPAA Authorization Form
• BlueCross Voluntary Group Dental Enrollment Form
• BlueCross Student Verification Form
• BlueCross Common Law Marriage Affidavit
• BlueCross Personal Blue Enrollment Form

Delta Dental of Oklahoma

• Delta Dental Enrollment & Change Form
• Delta Dental Enrollment & Change Form Electronic Fill-In
• Delta Dental Claim Form
• Delta Dental HIPAA Authorization
• Delta Dental EyeMed Information

Fort Dearborn Life

• Fort Dearborn Life Enrollment Form
• Fort Dearborn Life Death Claim Form

Genworth (GE Financial)

• Genworth Beneficiary Change Form

Hartford

• Hartford Beneficiary Deesignation Form
• Hartford Death Claim Form

MetLife

• MetLife Enrollment Form
• MetLife Beneficiary Designation Form
• MetLife Death Claim Form

PacifiCare

• PacifiCare Enrollment & Declination Form-Large Group
• PacifiCare Enrollment & Declination Form-Small Group
• PacifiCare Statement of Health
• PacifiCare Change Form
• PacifiCare PPO Medical Claim Form
• PacifiCare SDHP Medical Claim Form
• PacifiCare Prescription Claim Form
• PacifiCare Prescription Mail Order Form
• PacifiCare COBRA Election Form

Principal

• Principal Enrollment & Declination Form
• Principal Statement of Health
• Principal Change Form
• Principal Medical Claim Form
• Principal Prescription Claim Form

SunLife

• SunLife Enrollment Form
• SunLife Death Claim Form

Unicare

• Unicare Change Form

United Healthcare

• United Healthcare Enrollment Form-Large Group
• United Healthcare Enrollment Form-Small Group
• United Healthcare Medical Claim Form
• United Healthcare Prescription Claim Form
• United Healthcare COBRA Election Form
• United Healthcare HIPAA Authorization Form