Navajo Nation Employee Benefits Program

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Forms & Information

Forms

Enrollment Forms - New Hire/Change

Verdegard Enrollment Form Affirmation of Common-law Marriage Affirmation of Common Law Procedures CMS Data Collection for Section 111 Compliance Medicare D Notice (PDF) NNEBP Benefit Pamphlet (PDF) Summary of Benefits Coverage- English (PDF)

Health Benefit Forms

Native Traditional Healing Reimbursement Native Traditional Healing Procedures (PDF) Coordination of Benefits Questionnaire Explanation of Benefits Statement Verdegard Third Party Liability Questionnaire (PDF) Health Care Provider Nomination PNOA Medical, Dental & Vision Reimbursement

Pharmacy Benefit Forms

MedImpact Pharmacy Reimbursement MedImpact Home Test Kit Reimbursement MedImpact Prescription Mail Order Instructions MedImpact Prescription Mail Order Form

Member Portal Forms

HIPAA Release Form for Member Portal Verdegard Portal Instructions

Disability Forms

Disability Instructions & Application

Life Forms

Metlife Beneficiary Designation Metlife Addendum - Primary Beneficiary Metlife Addendum - Secondary Beneficiary Metlife Claim – Employer’s Statement Metlife Claim – Claimant’s Statement Metlife Accidental Dismemberment Metlife Accelerated Benefit Option Metlife Beneficiary Grief Counseling

Supplemental Forms

Metlife Optional Term Life Application Metlife Optional Term Life Statement of Health MetLife Optional Term Life Cancellation (PDF) Colonial Cancellation Form

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