CLAIM FORMS and INFORMATION

How to use our forms

 

Note: To ensure timely processing of your form, please be sure to follow the instructions precisely below.

 

All of our forms are in portable document format (pdf) and you must have Adobe Acrobat Reader installed on your computer or other device to view them.

 

Step 1:  Locate the form you need directly to the left.  Please print the form for manual completion.

 

Step 2:  Complete the form making sure to fill in all necessary and requested information.   

       It is extremely important that you read each form thoroughly and provide all additional requested information to accompany the form, such as receipts and/or EOBs.  

       If the form or any additional requested attachments are incomplete, the form can not be processed until all requested information is received.

 

Step 3:  Mail, Fax, or Scan the completed form and all requested supporting documentation (if any) to: 

 

Integrity Administrators, Inc.

ATTN:  Claims Department

P.O. Box 13128

Sacramento, CA 95813-3128

 

Fax  916.921.3383

 

Email:  claims@integrityadmin.com

Use this form, along with supporting documentation, to request reimbursement for any allowable dependent care expenses through your DCAP account.

Use this form, along with supporting documentation, to request reimbursement for any allowable medical, dental, prescription, etc.

expenses through your Flexible Spending Account.

Use this form, along with supporting documentation, to request reimbursement for any medical expenses that typically do not qualify for reimbursement from a Flexible Spending Account. 

Phone 800.562.9383    Fax 916.921.3383

© 1996-2017  Integrity Administrators, Inc.  All Rights Reserved

Integrity Administrators, Inc.

 

EXCELLENCE IN THIRD PARTY ADMINISTRATION

HIPAA COMPLIANCE

In compliance with privacy laws, please submit this form if you wish to allow any person, other than yourself, permission to contact us about your benefits or claims.   

This document outlines the HIPAA Privacy Rule and includes our policy on how we use Protected Health Information (PHI). 

This form is to be used, by LKSD employees only, to

request reimbursement for medical, dental or vision expenses.

Submission of these forms does not guarantee reimbursement.

Reimbursement will be provided according to

your benefits and accumulation thereof. 

This form is to be used, by LKSD employees only, to

request reimbursement for pre-authorized air travel expenses.

This form is to be used, by Kuspuk employees only, to request reimbursement for pre-authorized air travel expenses. 

LOWER KUSKOKWIN SCHOOL DISTRICT

KUSPUK SCHOOL DISTRICT

 

Members use this form to email questions for more help.