DMBA Forms Library

General Enrollment Forms

• Employee Benefit Enrollment Form
• Retiree Benefit Enrollment Form
• DMBA-affiliated HMO Applications
• Senior Dental Plan Enrollment Form
• Automatic Premium Debit Authorization Agreement
• Disability Direct Deposit Authorization
• Declaration of Insurability
• Authorization to Disclose Retirement or Life and Accident Benefit Information
• Authorization to Use and/or Disclose Protected Health Information (PHI)

DMBA Medical, Dental, and Prescription Forms

• Medical and Dental Claim Form
• International Medical and Dental Claim Form (for reimbursement of services received outside the U.S.)
• Navitus Prescription Drug Claim Form
• Navitus Foreign Prescription Drug Claim Form
• Member Appeal Form
• Member Benefit Suggestion Form
• Provider Nomination Form
• Provider Review Form
• Claim Information Request (for accident, injury, or illness)
• Home Sleep Study Physician FAX Order
• Home Sleep Testing History and Physical Questionnaire

COBRA Forms

• COBRA Election Form
• Notice of Qualifying Event
• Notice of Second Qualifying Event
• Notice of Disability
• Notice of Cessation of Disability
• Notice of Other Coverage or Medicare Entitlement

Medicare-related Forms

• Medicare Part B Claim Form

Flexible Spending Account (FSA) Forms

• Flexible Spending Claim Form for Healthcare Expenses
  (can be filled out online before printing)
• Flexible Spending Claim Form Dependent Care Expenses
  (can be filled out online before printing)
• Flexible Spending Enrollment
  (can be filled out online before printing)
• Flexible Spending Letter of Medical Necessity
  (can be filled out online before printing)
• Flexible Spending Direct Deposit Authorization

Life Benefit Forms

• Beneficiary Form   Review and designate your beneficiaries online right now.
• Supplemental Group Term Life Application
• 24-Hour Accidental Death & Dismemberment Application
• Retiree Supplemental Group Term Life Application
• Retiree Supplemental Group Term Life Application (hired on or after April 1, 2010)

Financial Benefits Forms

• Beneficiary Form   Review and designate your beneficiaries online right now.
• Authorization to Disclose Retirement or Life and Accident Benefit Information

Deseret 401(k) Forms

To access Deseret 401(k) Plan forms, log in to www.dmba.com. On your dashboard, go to the Deseret 401(k) Plan tile and click on Access Account. This will redirect you to Empower Retirement's website.

• Form W-4P federal withholding form (Savings)

Master Retirement Plan

• A Guide to Your Payment Options
• Information release - participant
• Information release - employer
• Master Retirement Plan and Savings Annuity Direct Deposit Authorization
• Form W-4P federal withholding form (Retirement)
• Request for State of Utah Income Tax Withholding
• Form A-4 Arizona withholding form
• Form DE-4P California withholding form
• Form ID W-4 Idaho withholding form