Forms & Resources

Weekly Cost Sheet

• 2023 Weekly Cost Chart

Adoption Assistance Program

• Adoption Assistance Reimbursement Form

Legal Notices & Other Forms

• PR 2023 Summary of Benefits and Coverage
• PR 2021 Certificate of Major Medical
• PR 2023 Certificate of Major Medical – Spanish
• PR Medicare Part D
• PR 2023 Benefits at Separation
• Long-Term Cash Retirement Provision
• Transparency in Coverage – Machine Readable Files
  
  • Triple S creates and publishes the MRFs for the medical plan offered in Puerto Rico. To link to the Machine-Readable Files, please click on the URL provided: https://salud.grupotriples.com/en/transparency-in-coverage-machine-readable-files/

Beneficiary Forms

• Beneficiary Change Form
• Domestic Partner Affidavit

Disability

• PR Disability Application
• PR Short-Term Disability Claim Process