Forms

General Forms
Membership Change Report
Group Health Plan Designated Contact Form

HIPAA Authorizations
HIPAA Member Authorization Form

Enrollment & Claim Forms
Employee Application/Change Form

Independence Blue Cross Forms
Application to Continue Coverage for Handicapped Dependent Child (#01418)
Personal Choice PPO Out of Network Claim Form
Optum Prescription Mail Order Form
Point of Service Claim Form (#03925)

Individual Forms
Application for Individual Coverage
Application for Adult Vision Individual Coverage
Application for Adult Dental Individual Coverage

Health Savings Account Forms
Contact DTL for H S A forms

United Concordia Forms
UCCI Dental Enrollment Form
UCCI Claim Form