Forms

Cordination of Benefits

Claims Form (Not For FSA/HSA/HRA/DCAP)

Appointment of Personal Representative Form

Dependent Care Reimbursement Form

Select Flex/HSA/HRA/MERP Reimbursement Form

New Provider Access

Employee Recognition

1095 Worksheet - SAMPLE ONLY

If you wish, you may mail a completed form to:

Regional Care, Inc.
905 West 27th Street
Scottsbluff, NE 69361Fax - (308) 635-2018
Flex Fax - (308) 635-1241

For Assistance, Please Call:
(308)635-2260 or (800)-795-7772