Forms & publications

Can't find what you need? Visit UMP Forms and publications for more documents.

ABA Services Authorization Form

This form is for requesting preauthorization of Applied Behavior Analysis (ABA) Therapy services.

Form

ardon-phi-disclosure-authorization-form.pdf

Ardon Health Protected health information disclosure authorization form

Form

Employee authorization for payroll deduction to health savings account (HSA) 2019

50-098-2019

Use this form to have your employer withhold money from your paychecks and deposit it into your health savings account (HSA) on a pretax basis. Check with your payroll department before submitting this form; not all employers can arrange for payroll deductions. You must be enrolled in a consumer-directed health plan (CDHP) with an HSA before you can start a payroll deduction.

Form

WSRxS Authorization for Release of Confidential Information

This form is to authorize the use or disclosure of personal health information.

Form