LuminX For Employers
		Forms
		PPO Provider Networks
		Request Change of Address
		Request an ID Card
		Contact Customer Service

For your convenience, frequently used forms are provided here in PDF format for easy downloading and printing using Adobe Acrobat® Reader. (Click here if you need to download this free software from Adobe’s web site.)

The following forms are available – just click to view or download for printing.

Medical / Dental Claim Form

FSA Dependent Care Reimbursement Form

FSA Health Care Reimbursement Form