Forms for your local Samaritan Human Resources Department
The following forms need to be turned into your local Samaritan Human Resources Department for approval:
Affidavit of Domestic Partnership:
Add a person to the health plan as a Domestic Partner if criteria have been met.
Declination of Coverage:
Samaritan offers an additional amount in each paycheck to employees who decline health plan coverage even though they are eligible. The amount of the additional income is determined by Samaritan each year. To decline coverage, you must complete and submit this form within 30 days of the close of open enrollment each year. You must be able to provide proof of other coverage.
Wellness Plus reimbursement form
Use this form to request annual reimbursement for the Wellness Plus benefit. Follow instructions that indicate where to send this form. DO NOT fax or mail to Samaritan Choice Plans. Go here for details on this benefit.