Office of Group Benefits

State of Louisiana

Official Website: https://www.doa.la.gov/doa/ogb/

Forms & Documents

Browse all Office of Group Benefits government forms

21 - 40 of 62 forms

Form Title Topics
GB-07 Participation Research Request
GB-12 HIPAA Authorization for Dependent Child Medical Information Request Form
GB-14 HIPAA Privacy Complaint
GB-15 HIPAA Request for Access to Protected Health Information
GB-18 HIPAA Request for Restriction of Protected Health Information
GB-19 HIPAA Revocation of Authorization for Use or Disclosure of Health Information
GB-20 2025 Medicare Part D High-Income Surcharge Verification
GB-20 2026 High-Income Form
GB-21 Retiree 100 Application
GB-76 Additional Agency Contact(s) Form
GB-77 Designation of Invoicing Contact
GB-78 Designation of Eligibility/e-Enrollment Contact
GB-79 Health Savings Account Enrollment & Payroll Deduction Election/Change Form
GB-79 Health Savings Account Enrollment & Payroll Deduction Election/Change Form
GB-80 Additional Agency Invoicing Contacts
GB-99 Retirement Eligibility Attestation Form
Group Accidental Injury Claim Form (AD&D)
Group Life Insurance Claim Form for Agencies/School Boards
Group Life Insurance Claim Form for Beneficiaries
Guaranty Association Notices

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