Forms
Select from the categories to find the form you need:
Caremark Forms HIPAA Privacy Forms Claim Forms Eligibility Forms Pre-Existing Condition Forms EssentialCare Forms
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Caremark Forms
Mail Service Order Form
Prescription Drug Claim Form
Prescription Drug Card Brochure
2007 Preferred Drug List
2008 Preferred Drug List
HIPAA Privacy Forms
Please submit completed forms to:
Corporate Privacy Office
Planned Administrators, Inc.
P.O. Box 6927
Columbia, SC 29260
NOTICE OF PRIVACY PRACTICES
NOTIFICACIÓN DE PRÁCTICAS DE PRIVACIDAD (Español)
Authorized Representative Form
Formulario de Representante Autorizado (Espanol)
Access Request (for individual to inspect/obtain copies of his/her PHI in record sets)
Amendment Request (request to amend PHI)
Authorization Form (Health Plan)
Authorization for Marketing
Complaint Form
Confidential Communications Request
Disclosure Accounting Request
Restriction Request
Authorized Representative Form (English)
Protected Health Information (PHI) is not released to anyone other than those specifically authorized by the insured using this form.
Formulario de Representante Autorizado (Español)
La Información Protegida de la Salud (PHI) no es liberada a nadie de otra manera que esos específicamente autorizado por el utilizar asegurado esta forma.
Dental Claim Form
If your plan includes dental coverage, this form is to be completed by the employee, provider, or employer for payment of claims. Attach itemized statements, including date, type and place of service, fees, and signature of provider or representative.
(Si su plan incluye el alcance dental, esta forma deberá ser completada por el empleado, por el proveedor, o por el empleador para el pago de reclamos. Conecte las declaraciones detalladas, inclusive la fecha, el tipo y el lugar del servicio, de los honorarios, y de la firma de proveedor o representante.)
Medical Benefits or Short Term Disability (English)
This form is to be completed by employee and signed as noted on form by employee and/or employer. This form is to be used for employee or covered dependents for submission of medical claims or short term disability claims. Itemized statements should be attached detailing expenses claimed and should include date, type and place of service, charge and signature of the provider or representative.
Forma de Demanda Para Beneficios de Groupo Medico / Invalidez Para Un Periodo Corta (Español)
Esta forma deberá ser completada por empleado y firmado como notado en la forma por empleado y/o empleador. Esta forma deberá ser utilizada para el empleado o cubierto los dependientes para la sumisión de reclamos médicos o reclamos cortos de incapacidad de término. Las declaraciones detalladas se deben conectar detallando los gastos reclamado y debe incluir la fecha, el tipo y el lugar del servicio, la carga y la firma del proveedor o el representante.
Subrogation Information Form and Reimbursement Form (English)
When there is the potential for other parties' liability, this form is used to assist in the recovery and settlement of the claim expenses, as outlined in your Summary Plan Description.
Eligibility Forms
Authorized Representative Form (English)
Protected Health Information (PHI) is not released to anyone other than those specifically authorized by the insured using this form.
Formulario de Representante Autorizado (Español)
La Información (PHI) Protegida de la Salud no es liberada a nadie de otra manera que esos específicamente autorizado por el utilizar asegurado esta forma.
Coordination of Benefits Form (English)
To be completed by the insured to verify that a patient does not have coverage other than their group health plan administered by PAI, or coordinate coverage between two plans. This information needs to be updated annually.
Formulario de Coordinación de Beneficios (COB) (Español)
Para ser completado por el aseguró para verificar que un paciente no tiene el alcance de otra manera que su plan de la salud del grupo administrado por PAI, ni coordina el alcance entre dos planes. Estas necesidades de la información para ser actualizadas anualmente.
Employee Termination Form
The Employee Termination Form should be completed for each terminated employee. The form indicates whether or not the employee elected to have COBRA coverage. If the employee does elect COBRA, the form must be attached. Please refer to Plan Document for specific policy information.
Enrollment/Change Card Form
This form is to be completed and returned to PAI every time a new employee elects to receive medical coverage and when an employee's pertinent information changes (i.e. address change, birth of child, etc.) This Enrollment Form must be signed by the employee regardless of whether or not he/she elects to have health coverage. There is a place for an employee to sign in order to elect or decline coverage.
Tarjeta de Inscripción/Cambio Forma (Español)
Esta forma debe ser completada y devuelta a PAI siempre un nuevo empleado decide recibir la cobertura médica y cuando la información pertinente de un empleado se cambia (es decir cambio de dirección, el nacimiento del niño, etc.) Esta Forma de Inscripción debe ser firmada por el empleado sin tener en cuenta si él/ella decide tener la cobertura de salud. Hay un lugar para un empleado para firmar a fin de decidir o rehusar la cobertura.
Full-Time Student Status Request (English)
This form is to be completed and returned to PAI to verify the status of dependents who are full-time students enrolled in an accredited college or university.
Estudiante de Tiempo Completo Solicitud de Condición (Español)
Esta forma deberá ser completada y deberá ser vuelta a PAI para verificar la posición de los dependientes que son estudiantes de jornada completa matriculados en un colegio o la universidad acreditados.
Pre-existing Condition Forms
Insured Pre-Existing Information Form (English)
To be completed by the insured, so claims will be processed correctly according to conditions existing prior to coverage with the claimant's group benefit plan.
Formulario de Información Preexistente (Spanish)
Para ser completado por el asegurado, así que los reclamos se procesarán correctamente según las condiciones que existen antes de alcance con el plan del beneficio del grupo de demandante.
Provider Pre-Existing Information Form
PAI uses this form to communicate with medical providers so that claims will be processed correctly according to conditions existing prior to coverage with the claimant's group benefit plan.
EssentialCare Forms
Agent Appointment Form
Broker Single Case Agreement Form
Business Associate Agreement between PAI and Broker
Form W-9, Request for Tax Payer ID Number and Certification