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Forms

If you need assistance completing any forms or have any questions, please call Customer Service at 1-866-798-0803. Representatives are available Monday through Friday, 8:30 a.m. to 8:00 p.m. Eastern Time. A translation line is available for most languages.

General Forms

Authorized Representative Form / Formulario de Representante Autorizado

Medical Claim Form / Formulario de Reclamo de Gastos Médicos

Prescription Drug Reimbursement Claim Form

Wellness and Preventive Reimbursement Claim Form

 

Limited Benefits Forms

Dental Claim Form

EyeMed Out-of-Network Claim Form

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

Short-Term Disability/Proof of Loss Form

Term Life / Accidental Loss of Life Claim Form

Discounts

Discount program

PAI HIPAA Forms

HIPAA-all groups