Benefit Forms

Fitness for Duty

This form is required prior to returning to work following an injury, illness, or surgery. 

American Fidelity FSA/HRA Manual Claim Form

Use this form to manually submit a claim to American Fidelity FSA/HRA claims.

Caremark Prescription Mail Order Form

For more information about Caremark Mail Order Service please visit their website. www.caremark.com

WPAS VSP Reimbursement Form

For reimbursement of vision claims.

WPAS Prescription/ Dental / Vision and Medical (Member Paid) Claim Form

*WPAS only processes out of Caremark network claims that are member paid.

All other prescriptions member paid claims should be submitted to Caremark and there are various methods to submit claims on www.caremark.com  where an employee can register and create an account.

WPAS Travel Preauthorization Form

Under certain circumstances your Plan may provide benefits for reimbursement of travel expenses
for you or your dependent(s) to travel outside your locale for medical treatment. Travel may be
considered for: treatment not available locally, treatment at Alaska Regional Hospital, or travel
outside Alaska to use Aetna PPO providers.

TRS Tier III Rollover Form

If you are looking to make a withdrawal from your 401k please fill out and submit to Empower Retirement.

Healthcare Enrollment Form

Make sure and submit any supporting documents with your enrollment form! These include your marriage certificate, birth certificates for children, or a waiver form if applicable.

• 2025 Non-Represented Health Care Enrollment Form

• 2025 ESSA, FEA, FPA Health Care Enrollment Form