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–including adding a newborn to your insurance (select ONE: Redoubt, Illiamna or Denali)

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 signed up for the Iliamna Plan, you may change your contributions throughout the year up to the allowable IRS yearly contribution

Declination of Coverage Complete this form ONLY if you are declining to purchase health insurance when you are eligible

Flexible Spending Account* Complete this form ONLY if you are signing up for a Flexible Spending Account (FSA) You may only sign up upon hire, during open enrollment or if you have a qualifying event.  You do not have to have health insurance through CPH to participate in an FSA.

Life and Accident Insurance* Complete this form to purchase additional coverage

Life & ADD Beneficiary Designation Complete this form to update your life insurance Beneficiary information

Short Term Disability* Complete this form to add Short Term Disability Coverage

Long Term Disability* Complete this form to add Long Term Disability Coverage

*may only sign up upon hire or during open enrollment

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