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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.

Accidental Loss of Limb or Sight Claim Form / Formulario de reclamo por pérdida de un miembro o de la vista por accidente

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

Authorized Representative Form / Formulario de Representante Autorizado

Dental Claim Form / Formulario de reclamo dental

EyeMed Out-of-Network Claim Form

Medical Claim Form / Formulario de Reclamo de Gastos Médicos

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

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.) If your Medical plan entitles you to pay a copay at the point of purchase and your prescription was not filed directly to OptumRx 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 - Proof of Loss Claim Form / Formulario de discapacidad a corto plazo - prueba de pérdida

Term Life - Accidental Death Claim Form / Formulario de reclamo del seguro de vida y seguro por muerte accidental

Termination-Loss of Coverage Form / Terminación-pérdida involuntaria de la cobertura

Discounts

Discount program

PAI HIPAA Forms

HIPAA-all groups