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For health providers to look up eligibility for insurance and benefits
  • See your Summary of Benefits using Coverage & Benefits Portal
  • Find in-network providers
  • Access your pharmacy benefits
  • See your claims status through the Benefits Portal
  • Learn more about other programs and services included with your plan
  • And much more.

Forms

If you need assistance completing any forms or have any questions, please call Benefit 4 Today’s toll-free Customer Service Line, 1-888-747-5770, 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

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