Forms

01

Association Application for a Small Employer Benefits Policy
(This form is used by the employer of new groups enrolling in the Cultural Alliance medical plans to provide information about the plans elected as well as specific company data)

• All areas, unless marked accordingly, must be completed and the form signed by an authorized company official.
• Make sure to indicate which Plans you are electing for the group. Groups with two to nine employees may elect two plans (one Keystone and one Personal Choice). Groups with 10 employees or more may elect up to three different plans (no more than two from each product line, Keystone vs. Personal Choice).

Association Application [48k]

02

Group Benefit Change Request Form

• Groups with existing medical plans through the Cultural Alliance use this form to request plan changes at renewal.

Group Benefit Change Request Form [58k]

03

Employee Enrollment Form

• This form is used to enroll employees into a group medical plan. It should be accompanied by the Independence Blue Cross Enrollment Report or Keystone Transmittal Form dependent upon which plan you are enrolling in)

Employee Enrollment Form [712k]

04

Independence Blue Cross Enrollment Report

• This form is used by the employer when enrolling or terminating an employee's coverage with Traditional Blue Cross or Personal Choice coverage. Please enclose this form with the Universal IBC/Keystone Enrollment/Change forms when adding employees to the health plan.

Independence Blue Cross Enrollment Report [70k]

05

Personal Choice Out of Network Claim Form

• Submit after receiving services from an out of network provider.

Personal Choice Out of Network Claim Form [108k]

06

Keystone Health Plan East Transmittal Form

• This form is used by the employer when making employee changes, enrolling new employees, or terminating employee's coverage. It should accompany the Universal IBC/Keystone Enrollment/Change Form when adding employees to the plan.

Keystone Health Plan East Transmittal Form [28k]

07

Keystone Point of Service Claim Form

• Employees can submit this form to Keystone after receiving services without a referral or from an out of network provider.

Keystone Point of Service Claim Form [40k]

08

FutureScripts Prescription Reimbursement Claim Form

• Submit for reimbursement after paying the full cost of a prescription drug.

FutureScripts Prescription Reimbursement Claim Form [104k]

09

Caremark Prescription Mail Order Form

• Submit for your maintenance prescription drugs you would like to have filled through Caremark's mail order service.

Caremark Prescription Mail Order Form [177k]

10

United Concordia Group Enrollment Form

• This form is used by the employer when enrolling in a group dental plan with United Concordia.

United Concordia Group Enrollment Form [144k]

11

United Concordia Enrollment Form

• This form is used by employees to enroll in the dental plan for the first time, add dependents or terminate dependents to the United Concordia dental plan.

United Concordia Enrollment Form [99k]

12

United Concordia Student Verification

• This form is used by an employee who needs to verify dependent student status.

United Concordia Student Verification [182k]

13

United Concordia Claim

• Submit if dental services are performed by an out of network dentist or if your dentist does not submit the claims for you.

United Concordia Claim [81k]

14

HIPAA Authorization Form

• Employees must complete and submit this form when they need Independence Blue Cross to release their health information for claim or other insurance purposes.

HIPAA Authorization Form [124k]

15

IBXpress Authorization Form

• Employers must complete this form and print it onto company letterhead to provide Gallagher Benefit Services with the authorization to administer employee additions, changes, and terminations online.

IBXpress Authorization Form [36k]