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Claim Forms Coordination of Benefits Form Employee Termination Form Enrollment/Change Form HIPAA Privacy Forms Prescription Drug Forms Pre-Existing Condition Forms Primary Care Physician Election Form Provider Medical Referral Form Subrogation Form
Dental Claim Form
If your plan includes dental coverage, this form is to be completed by the employee, provider, or employer for payment of claims.
Medical Benefits or Short Term Disability Claim Form
For submission of medical claims or short-term disability claims.
Coordination of Benefits Form
To verify that a patient does not have coverage other than the PAI group health plan or to coordinate coverage between two plans. This information needs to be updated annually.
Coordinación de Beneficios de Forma
Para verificar que un paciente no tiene cobertura que no sea el plan de salud de grupo PAI o para coordinar la cobertura entre dos planes. Esta información debe actualizarse anualmente.
Employee Termination Form
Group Benefit Manager completes for each terminated employee. The form indicates whether or not the employee elected COBRA coverage. Refer to Plan Document for specific policy information.
Complete every time a new employee elects medical coverage and when an employee's pertinent information changes (i.e. address change, birth of child, etc.).
Please submit completed forms to:
Corporate Privacy Office
Planned Administrators, Inc.
P.O. Box 6927
Columbia, SC 29260
Access Request (for individual to inspect/obtain copies of his/her PHI in record sets)
Amendment Request (request to amend PHI)
Authorization Form (Health Plan)
Mail Service Order Form (Caremark)
Use this form to order up to a 90-day supply of your prescriptions through Caremark's Mail Service prescription drug program.
Prescription Drug Claim Form (Caremark)
Use this form to file claims for covered prescriptions which you paid I00 percent, for covered prescriptions you received without showing your ID card, and for covered prescriptions you received from a non-participating pharmacy.
For Members with Other Drug Coverage
If your plan provides prescription drug coverage through another plan or vendor, refer to the back of your prescription drug ID card for contact information. Or, contact your benefits coordinator or Human Resources department at your place of employment.
Insured Pre-Existing Information Form
To be completed by the insured so claims will be processed correctly according to conditions existing prior to coverage with the claimant's group benefit plan.
Formulario de Información Sobre Preexistencia
Este formulario se usa para que los reclamos se procesen correctamente en lo relacionado a las condiciones que podrían haber existido antes de que empezara la cobertura de su plan de salud de grupo.
Provider Pre-Existing Information Form
PAI uses this form to communicate with medical providers so that claims will be processed correctly according to conditions existing prior to coverage with the claimant's group benefit plan.
Primary Care Physician Election Form
For individuals enrolled in a plan that requires designation of a primary care physician.
Provider Referral Form
For Bob Jones University employees.
Subrogation Information Form
When there is the potential for other parties' liability, this form is used to assist in the recovery and settlement of the claim expenses, as outlined in your Summary Plan Description.
Formulario de Información de Subrogación
Cuando existe la posibilidad de responsabilidad de otras partes, este formulario se utiliza para ayudar en la recuperación y la liquidación de los gastos de la reclamación, como se indica en la descripción resumida del Plan.
- Agent Appointment Form (BCS Insurance Company)
- Agent Appointment Form (4 Ever Life Insurance Company)
- Agent Appointmenf Forms (Companion Life Insurance Company)
- Broker Single Case Agreement Form (Crescent Medical Bridge Asset Protection)
- Broker Single Case Agreement Form (Essential StaffCARE)
- Broker Single Case Agreement Form (EssentialCare)
- Broker Single Case Agreement Form (HospitalityCARE, underwritten by 4 Ever Life Insurance Co.)
- Broker Single Case Agreement Form (HospitalityCARE, underwritten by Companion Life Ins. Co.)
- Broker Single Case Agreement Form (MyShare)
- Broker Single Case Agreement Form (Payroll Plans)
- Broker Single Case Agreement Form (SimplyMed/Rx)
- Business Associate Agreement between PAI and Broker
- Form W-9, Request for Tax Payer ID Number and Certification
- Choice Hotels
- Columbia Healthcare Services
- Crescent Medical Bridge Asset Protection Plan
- Dunkin' Donuts
- Employee Management Services
- Essential StaffCARE
- LaQuinta Inns & Suites
- MAU Workforce Solutions
- Medical StaffCARE
- ULTA Beauty