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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 (Indemnity) / Formulario de Reclamo de Gastos Médicos (Indemnity)

Medical Claim Form (MEC/MVP) / Formulario de Reclamo de Gastos Médicos (MEC/MVP)

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.)

Prescription Drug Reimbursement Claim Form (MEC)

 

Limited Benefits Forms

Accidental Loss of Limb or Sight Claim Form

Accidental Loss of Limb or Sight Claim Form-Attending Physician Statement

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 or Accidental Death Claim Form

Discounts

Discount program

PAI HIPAA Forms

HIPAA-all groups