Claims & Forms
Claims & Forms
At EPIC Specialty Benefits, we process insurance benefit claim forms right away. All you need to do is find the correct form, and then scan and email, fax, or mail it to us.
Claim Forms
- Hospital Surgery Benefit (Wisconsin State Employees)
- Rapid Pay Income Replacement (Short-term Disability)
- Rapid Pay Income Replacement Federal Income Tax Withholding Form
- Short-term Disability
- Short-term Disability Federal Income Tax Withholding Form
- Short-term Disability: Attending Physician – Update
- Life and AD&D
- LTD Claim Form
- Premium Waiver
- Long-term Disability
- Vision
Other Forms
- Employer’s Group Application (for use in Wisconsin only)
- Employee’s Application for Group Coverage (for use in Wisconsin only)
- Beneficiary Designation Form
- WSE Beneficiary Designation Form
- Authorization to Disclose Health-Related Information
- Appeals/Grievance Authorized Representative Form
- Complaint Form
- Notice of Privacy Practices
- Request for Access to Protected Health Information
- Instructions for Completing the Member Authorization Form
- Authorized Representative Form for Grievance/Appeal
- Fillable Authorized Representative Form for Grievance/Appeal
- Member Authorization to Release Member’s Protected Health Information (PHI)
- Authorization to use or Disclose PHI by Electronic Means
- Request for Confidential Communications of PHI
- Request for Amendment of PHI
- Privacy Complaint Form