Skip to content

Forms

If you need assistance completing any forms or have any questions, please call Benefit 4 Today’s toll-free Customer Service Line, 1-800-440-3068, Monday through Friday, 8:30 a.m. to 8:00 p.m. Eastern Time. A translation line is available for most languages.

 

Authorized Representative Form / Formulario de Representante Autorizado

Dental Claim Form / Formulario de Reclamo por Gastos Dentales

EyeMed Out-of-Network Claim Form

Medical Claim Form / Formulario de Reclamo por Gastos Médicos

Missed Premium-Direct Payment Form / Formulario Para el Pago Directo de Primas no Cubiertas

Prescription Drug Claim Form (Use this form if Rx group: ECPAI is on your ID card.) / Formulario de Reclamo de Recetas Médicas (Utilice este formulario si el grupo Rx: ECPAI está en su tarjeta de identificación.)

Prescription Drug Claim Form - (Use this form if Rx group: ECFDRX is on your ID card.) If your Medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to Caremark by the pharmacy, use this form to submit for payment.
    If your Medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the Medical Claim Form above.
    Please see your Summary Plan Description if you have questions as to which plan is associated with your group.

Short-Term Disability Claim Form / Discapacidad a corto plazo Formulario de Reclamación

Term Life-Accidental Death Claim Form / Reclamo del Seguro de Vida y por Muerte Accidental

 

HIPAA Forms