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Benefit Forms

Central Peninsula Hospital self-insures our health care plan. This means that we assume all of the financial risk for providing health care benefits, rather than paying an insurance company to assume this risk. Moda Health is the claims administrator for our medical, vision, dental and prescription drug plans. The main goal of this plan is to provide a high level of coverage for employees and their families as well as reduce costs. 

If you are making any changes to your health insurance elections,
select and fill out the appropriate forms:

To complete the forms, first download and fill in your information. 
Signatures can be added by clicking the "Sign" icon at the top of the page
 Completed forms may be saved and emailed to srandall@cpgh.org or printed and dropped off in HR. 
Paper copies of forms are available outside the HR Department.

Health Insurance Enrollment Form Complete this form ONLY to enroll,change Plans or to add/drop dependents

Health Reimbursement Account Complete this form ONLY if you are signing up for the Redoubt Plan for the first time

Health Savings Account Complete this form ONLY if you are signing up for the Iliamna Plan

Declination of Coverage Complete this form ONLY if you are declining to purchase health insurance at this time

Flexible Spending Account Complete this form ONLY if you are signing up for a Flexible Spending Account (FSA)

    Still have questions?  Contact CPH Human Resources at extension 4771 or email Stephanie Randall at srandall@cpgh.org