PAI, The TPA with your needs in mind.

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.

Enrollment/Change Form
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

NOTICE OF PRIVACY PRACTICES / NOTIFICACIÓN DE PRÁCTICAS DE PRIVACIDAD

Authorized Representative Form / Formulario de Representante Autorizado

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)

Authorization for Marketing

Complaint Form

Confidential Communications Request

Disclosure Accounting Request

Restriction Request

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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.