Insurance Forms Document Center

This document center includes frequently used forms for all the plans provided through the Chemung County Insurance Department. If you are not sure which forms you should complete, refer to your union or group plan summary (links below) with plan lettering to verify which plans pertain to you or contact the Chemung County Insurance Department. 

 Chemung County Employee Benefits

Municipality/Special District Employees

Eligibility requirements should be discussed with the Chemung County Insurance Department or your participating employer group.

Refer to the Subscriber Responsibility (PDF)  for dependent eligibility and required documentation.

All enrollment forms must be returned to the Chemung County Insurance Department for processing. Do not submit them directly to your insurance plan carrier.  The 'other insurance coverage information' form should be completed every time you complete enrollment forms.

All claim forms are sent to your insurance plan carrier directly.  Do not send them to the Chemung County Insurance Department.

Are you looking for Chemung County Employee Insurance Buyout Form or Chemung County Employee Change Coverage Form? Those forms are only posted on the County Intranet site under Insurance.


A, B, C, J - Chemung County HIPAA Authorization Form (PDF)

A, B, C, J - SUMMARY OF BENEFIT AND COVERAGE (SBC) AND GLOSSARY

A, B, C, J - Chemung County Forms

  1. A, B, C, J - HEALTH INSURANCE ELECTION FORM - All Chemung County Employees
  2. A, B, C, J - OTHER INSURANCE COVERAGE INFORMATION FORM - All members

A, B, C, J - EXCELLUS Forms 

  1. A, B, C, J - Excellus HIPAA Privacy Policy
  2. A, B, C, J - Excellus HIPAA Authorization Form

A, B, C, J, D - EXCELLUS Classic Blue, Blue PPO, Blue PPO 2, Blue PPO 3, Rx and Dental Plan Forms

  1. A, B, C, J, D - Enrollment form for the Classic Blue, Blue PPO, Blue PPO 2, Blue PPO 3, prescription and dental plans
  2. A, B, C, J - Excellus Medical Claim Form
  3. D - Excellus Dental Claim Form
  4. A, B, C, J - Claim form for Classic Blue and Blue PPO Plans
  5. D - Claim form for the Dental Plan
  6. Dependent Certification Form Excellus Dental 2023

E, G - LIFETIME BENEFIT SOLUTIONS - coverage ended 12/31/21

F - CSEA PLATINUM 12 VISION Form

  1. F - Enrollment form for CSEA Platinum 12 Vision Plan (CSEA and Sewer District union only)

A, B, C, J - Excellus MAIL ORDER Forms

  1. A, B, C, J - Express Script Order Form
  2. A, B, C, J - Wegmans Home Delivery Order Form

H - UNITED HEALTHCARE Medicare Plan 1/1/22

  1. 2023 UHC Enrollment Form

G - GUARDIAN VISION 1/1/22

  1. Enrollment Form
  2. VSP Out-of-Network Claim Form