Healthcare forms and useful links

Healthcare forms, useful links and additional information


Dental Claim Form (includes instructions and related documentation)

Dental eBrochure: Healthy Mouth = Healthy You

Healthy Mouth = Healthy You


Expatriate Prescription Drug Authorization Form (Express Scripts)

Medical Claim Form POS II (Including instructions)

Medicare Supplement Plan Claim Form

Ordering medications from Express Scripts by mail (mail order pharmacy)

Prescriptions Claim Form (Express Scripts)

Pre-Tax Spending Plan (Flexible Spending Account)

Employee Dependent Care Affidavit - Flexible Spending Account Dependent Care Reimbursement Account

Employee Health Care Affidavit - Flexible Spending Account Health Care Reimbursement Account

Pre-Tax Direct Deposit Form

Dependent Care Flexible Spending Account Claim Form

Health Care Flexible Spending Account Claim Form

Pre-Tax Claim Instructions

IRS Publication 502 - Medical and Dental Expenses

IRS Publication 503 - Child and Dependent Care Expenses

IRS Publication 2441 - Instructions for Child and Dependent Care Expenses

IRS Form 2441 - Child and Dependent Care Expenses


ExxonMobil Vision Plan

U.S. Expats & Rotators mail order anti-malarials

Anti-Malarial Mail Order Program Notice

ExxonMobil Expat Skill Center Letter to Employees Explaining the Program

ExxonMobil Malaria Chemoprophylaxis Prescription Fax Order Form

  • Word document (you can edit, save and attach to an e-mail)
  • PDF document (you can print, write on changes, bring or mail to prescriber - changes cannot be saved)

Medical information and disclosure

Useful links



Express Scripts (formerly Medco)

HMO IL, Blue Cross/Blue Shield

Kaiser S. CA

Spectera Vision

Magellan Healthcare