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Individual & Group Coverage: (800) 400-PCHP
Medicare Advantage: (877) 210-1719

Employer Forms

Piedmont has provided this section for employers and Group Administrators to access any needed hard copy forms.  If you need mulitple copies or a supply of enrollment packets, please contact us directly with your request by phone at 434-947-4463, ext. 204, or by This email address is being protected from spambots. You need JavaScript enabled to view it.

Otherwise, you can download printable forms by clicking on the following

Medical Claim Form
This is the form the employee needs to submit when filing a claim for an out-of-network provider, or for reimbursement for advance payment.

Prescription Claim Form
This is the form the employee needs to submit when filing a claim for prescription cost reimbursement.

Prescription Mail Order Form
This is the form the employee needs to submit when requesting a 90-day supply of maintenance medication by mail (don't forget to advise them that they can also use one of the "walk-in" 90-day supply participating pharmacies).

Dependednt Out-Of-Netowrk Form
This form needs to be submitted by the employee for all out-of-area covered dependents attending college.

LocalSelect PPO Enrollment Form
This is the standard PPO enrollment form that every employee must submit to Piedmont. We prefer that you use the 3-copy printed form that we supply you with. 

Self-insured Enrollment Form
This is the standard enrollment form for self-insured groups.

•  COBRA Renewal Form
Members must fill out this form to continue in the COBRA administration plan.

•  COBRA Setup Form
This is the form employers use to initially set someone up with COBRA.