Health, Vision and Dental

1. Aetna - Advantage Plans for Individuals and Families - HMO and PPO - PA (PDF)
2. Aetna - PA Small Group Business (2-50 Eligible Employees) - Enrollment/ Change Form (PDF)
3. Capital Blue Cross - Application to Enroll or Change Enrollment (PDF)
4. Capital Blue Cross - Express Scripts Prescription Drug Claim Form (PDF)
5. Capital Blue Cross - Handicapped Dependent Certification Form (PDF)
6. Capital Blue Cross - Medical Expense Claim Form for Traditional, Comprehensive, PPO, PPO Plus, Senior, and Security (PDF)
7. Capital Blue Cross - Waiver of Group Health Insurance Coverage (PDF)
8. Capital Blue Cross - National Vision Administrators - Claim For Vision Care Expense (PDF)
9. Census Form - Generic (PDF)
10. Highmark Blue Cross Blue Shield - Enrollment Application - Change Form (PDF)
11. Highmark Blue Cross Blue Shield - Small Group Business Application (PDF)
12. Highmark Blue Cross Blue Shield - Out-of-Area Hospital Claim Form (PDF)
13. Highmark Blue Shield - Enrollment Application (PDF)
14. Highmark Blue Shield - Claim Form (PDF)
15. Highmark Blue Shield - Member Change Form (PDF)
16. Highmark Blue Shield - Prescription Drug Reimbursement Form (PDF)
17. Highmark Blue Shield - Vision Claim Form (PDF)
18. Highmark Blue Shield - Waiver of Insurance Coverage (PDF)
19. Independence Blue Cross/ Keystone - Census Form (PDF)
20. Independence Blue Cross/ Keystone - Forms Online Website
21. Independence Blue Cross/ Keystone - Group Enrollment/ Change Form (PDF)
22. Independence Blue Cross/ Keystone - Medical Application/Change Form (PDF)
23. Independence Blue Cross/ Keystone - Universal Enrollment Form (PDF)
24. Independence Blue Cross/ PBS - Student Verification Form (PDF)
25. Independence Blue Cross - Group Application Form for Security 65 Coverage (PDF)
26. Independence Blue Cross - Indemnity Claim Form (PDF)
27. Independence Blue Cross - Mail Service Order Form (PDF)
28. Independence Blue Cross - Personal Choice - Out-of-Network Claim Form (PDF)
29. Independence Blue Cross - Prescription Reimbursement Claim Form (PDF)
30. Keystone - Health Plan East - Dependent Verification Form (PDF)
31. Keystone - Health Plan West - Application (PDF)
32. Keystone - Health Plan West - Change Form (PDF)
33. Keystone - Health Plan West - Claim Form (PDF)
34. Retired Employees' Benefits Coalition - United Concordia Dental and Clarity Vision Enrollment Form (PDF)
35. United Concordia - Claim Form - Submit to Harrisburg (PDF)
36. United Concordia - Dental Dependent Certification Form (PDF)
37. United Concordia - Dental Enrollment/ Change Form (PDF)
38. UPMC Health Plan - HMO and POS Application (PDF)