ABX Benefits Forms & Notices


Medical Forms

ABX Air United Health Care Medical Claim Form

Optum Rx Mail Order Form    (Use on or after June 1, 2013)

Optum Rx Mail Order Fax Form (Use on or after June 1, 2013)

International United HealthCare Form

Optum Health Bank application for the HSA

2019 Fitbit Purchase Form (AMES)

2019 Fitbit Purchase Form (Other ATSG companies)


Dental & Visions Forms 

ABX Air MetLife Dental Claim Form

MetLife Dental Card

ABX Air EyeMed Vision Care Form

EyeMed Out-of-Network Claim form


Flexible Spending Accounts Forms

UHC Medical and Dependent Care Flexible Spending Account  (Updated Jan. 2013)



Beneficiary Forms 

Full-time Beneficiary Form 

Part-time Beneficiary Form 

Flight Crewmember Beneficiary Form

Profit Sharing Beneficiary Form


Family Medical Leave Forms (revised June 1, 2015)

Family Medical Leave Request

Medical Certification for Employee

Medical Certification for Family Member

Certification for Military Member


Other Forms

Personal Leave Request form 37kb PDF


Required Notices 

Creditable Coverage Notice

Forms require Adobe Acrobat Reader.  You can download the latest version from Adobe:

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Revised: March 29, 2022.