Customers Forms Wellness Contact Us Legal

If you received services from a participating provider, your claims will automatically be filed for you. Itís that simple! However, should you still need a claim form or another type of form, simply click on the name of the form below and press print. The completed forms should be returned the appropriate personnel at the Benefits Department at the Employer. Please click on the appropriate link(s) below to view the document in Adobe Acrobat Reader (.pdf) format.

Enrollment Form Group Health (28XX1109)

Adding Additional Dependent Card (28XX1398)

Plan Participant Change Card (28XX1402)

Continuity of Care Request Form (28XX1584)  NEW

BMS Benefit Change Form 31BM0069 01/11  NEW

If your doctor leaves the Access Care or Access Care PPO networks while you are receiving care for certain conditions, you may be eligible to continue care with your doctor at the higher network level of benefits for a limited time. This form must be completed by you and your doctor, and returned to us within 30 days of the doctor leaving our networks.

Coverage Termination Card (28XX1400)

COBRA Enrollment Card (28XX1425)

Dependent Certification (28XX1298)

Other Coverage Questionnaire (28XX1112)

Accident/Injury/Illness Form (28XX1111)

Medical Claim Form (28XX1147)

Attending Dentistís Statement (dental claim form) (28XX1095)

Authorized Delegate Form (28XX1411)

Prescription Drug Claim Form (28XX1108)

St. Tammany Enrollment Form (28XX1544)

If you are having problems downloading files, please click here.

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