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Medical

You can find all the necessary forms and documents to manage your medical benefits here.

Form

Description

2019 premiums for medical and dental plans for active employees, retirees and COBRA participants.

Form used to submit Medical claims to your health insurance.

 

Form used to submit Vision claims to your health insurance. (Fill with Acrobat)

Form used to submit dental claims.

This form must be completed for your enrollment in the medical and/or dental insurance program. (fill with Acrobat)

Use this form to make changes to your enrollment information for your medical and dental insurance; i.e., add dependents, remove dependents, change marital status, address, etc.

This is the form you sign to waive participation in the health insurance.

2020 premiums for medical and dental plans for active employees, retirees and COBRA participants.

2020 Easy-to-read description of most frequently used coverage in the Employee Choice/HRA Plan as required by Health Care Reform.
 

Explanation of terms used in the Summary Plan Description

Complete description of the Employee Choice medical plan and the coverage. 

Complete description of how the Health Reimbursement Account (HRA) works.

2020 Easy-to-read description of Basic Health Plan with Health Savings Account Option. 

Complete description of Basic Health Plan with Health Reimbursement Account Option 

Dental Summary Plan Description 
1/1/18 (Valid until updated)

Complete description of the Dental Plan coverage

The Public Safety Employee Benefits Act (PSEBA) states that qualified sworn police and fire personnel injured in the line of duty may receive certain medical benefits if they can no longer perform their duties. This is the form used to apply for those benefits and the ordinance provides more details on the application process.

The City of Lake Forest complies with all HIPAA privacy requirements with regard to your personal health information. Our privacy practices are found here.   

Our Notice about your Prescription Drug Coverage and Medicare Part D is found
here.   

The Women's Health and Cancer Rights Act of 1998 requires that all employees be notified on an annual basis of their coverage, and can be found here.

This benefits summary is intended to provide general information regarding benefits for fulltime employees and is not meant to be all-inclusive.