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

 

Dental & Visions Forms 

ABX Air MetLife Dental Claim Form

MetLife Dental Card

ABX Air EyeMed Vision Care 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

Employee Stock Purchase Plan Enrollment Kit

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: October 13, 2017.