MMIA EB program

Choose this option if you are enrolling for the first time such as:

• A newly hired employee,
• An employee who recently became benefit-eligible
• The spouse of a retiree or employee who wants to join the plan
• The surviving spouse of a deceased employee, or an eligible elected official
• Updating contact information
• Requesting replacement ID cards

Or if you are removing all MMIA EB coverages for an employee/retiree and all spouse/dependents covered under their benefits.

Benefit Enrollment & Termination Form

Choose this option if you are an existing employee or retiree and you want to make a change to your benefits such as:

• Updating contact information
• Requesting replacement ID cards
• Adding or removing coverage or adding dependents
• Removing dependents - This can be done at any time for any reason.
• Letting your city and MMIA EB know you are retiring and would like to retain some of all of your current MMIA coverages
• Letting your city and MMIA EB know you or someone on your plan has become Medicare‐eligible

Employee Benefits Online Change Form

Voluntary Term Life Enrollment (PDF)

Basic & Voluntary Life Beneficiary Form (PDF)

Evidence of Insurability (PDF)

Affidavit to Enroll Domestic Partner (PDF)

Common Law Marriage Affidavit (PDF)

Use the following forms to manually request claim reimbursement or visit the vendor’s website to do it online.

Medical Claim Reimbursement PDF Form

          - Vendor: www.AskAllegiance.com

Vision Out-of-Network Claim Reimbursement PDF Form 

          - Vendor: www.VSP.com

Proact Prescription Reimbursement Proact Prescription Reimbursement Form 1PDF Form 

          - Vendor: https://secure.ProActRX.com/

Ridgeway Mail Order Prescription PDF Form

          - Vendor: https://Ridgeway.Pharmacy/

CRx formerly known as MMIA Scripts (web ID: MMIA) https://www.crxintl.com/

Authorization for Release of Information Form (PDF)