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Forms

Browse the list below to locate the Form you are looking for. Benefit specific documents are found on their respective pages.

Dental

Metlife Dental Expense Claim

Dental Claim Form

Enroll

Working Spouse Employer Verification Form
Working Spouse Employer Verification Form (Editable)

Health Care Enrollment Change Form
Health Care Enrollment Change Form (Electronic Fillable)

Health Care Waiver Form [Word Document]
Health Care Waiver Form [PDF File]

Health Enrollment Form – Medicare 2019 [Word Document]
Health Enrollment Form – Medicare 2019 [PDF File]

Health Insurance Plans

Medical Mutual Claim Form

HSA

HSA Payroll Deduction Authorization

CVS Caremark

CVS Caremark Mail Service Form

Physical & Tobacco Attestation

Annual Physical & Tobacco Attestation Form With Instructions – 2025-26

Annual Physical & Tobacco Attestation Form With Instructions – 2025-26 – Fillable

Employers

Below is information needed by employers in order to administer various aspects of the benefit plans. If you don’t see the information you’re looking for please contact the Diocese Health Benefits Office at 216-696-6525 x5040 or email us at [email protected].

Determination of Full-Time Employees Form

Termination Of Coverage Form

PNC Employer Contact Change Form

Marketplace Notice Form

Marketplace EE Notice Cover Letter

Creditable Coverage Certificate 2024

Notices

Creditable Coverage & Required Notices

CHIP Notice

Notice of Privacy Practices for Medical Information

Health Insurance Marketplace Notice

Catholic Diocese of Cleveland
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