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Forms

If you need assistance completing any forms or have any questions, please call HospitalityCare customer service at 1-888-583-3057. 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.

Accidental Dismemberment Claim Form

Accidental Dismemberment Claim Form-Attending Physician's Statement

Accidental Loss of Limb or Sight Claim Form

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

Authorized Representative Form  /  Formulario de Representante Autorizado

Dental Claim Form

EyeMed Out-of-Network Claim Form

HIPAA Complaint Form (BCS)

HIPAA Complaint Form (Companion)

Medical Claim Form

Missed Premium Direct Payment Form

Prescription Drug Claim Form (Use this form if RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Claim Form - (Use this form if RxGRP: BXPAI is on your ID card.) 

Short-Term Disability - Proof of Loss

Term Life / Accidental Death Claim Form

 

Discounts

Discount program

PAI HIPAA Forms

HIPAA-all groups