Dillard's Employee Member Forms

Member Forms and Information

Appeals Rights & Requests

Form Name
Member Appeal Request Form
Right to Appeal Notice

Group

Form Name
Coordination of Benefits Questionnaire
Dependent Certification Form
Designation of Personal Representative
Disabled Dependent Request for Extension of Coverage
HRA Claim Form
Medical Claim Form
Preventive Care Benefits
Preventive Care Benefits - ES
Request for Personal Health Information
Transplant Travel and Lodging Expense Form
Where to Go For Care - ES

Educational Materials

Form Name
Asthma Medication Ratio: Ages 19-64 (AMR)
Managing Heart Failure
My Heart Failure Management Guide
Prevention of Diabetic Hospital Admissions

QCARE Health Management Programs

Form Name
Diabetes Assessment Form
Hypertension Assessment Form
Maternal Health Appraisal Form
Maternity Notification Form