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

Member Forms

forms 2Normally claims are submitted by the Piedmont network provider.  Following that, the member will get a Piedmont statement regarding what was paid out by Piedmont to the provider and advising the member if they have any financial responsibility.  However, if you use an "out of network" provider, or if you are in a situation when you have to pay "up front" for medical services and then need to be reimbursed, you will have to submit one or more of the below forms to Piedmont.  You can download these printable Member Forms by clicking on the following:

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

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

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

4 COBRA Renewal Form
This is the form that you must fill out to continue to be enrolled in the COBRA administration plan.

4 Dependent Out-Of-Area Form
This form needs to be submitted for all out-of-area covered dependents attending college.

4 Appeal Request Form
This fillable form is used by members to request an appeal. 

4 Additional Services Brochure
This is the printable version of the Piedmont Additional Services Brochure, but you may also check out the merchants by going here.

4 Transition of Care Form PPO
4 Transition of Care Form HMO
This form must be submitted to advise us of care already established with an out of network provider or facility.

4 Member Release Form for Piedmont Community Health-PLAN members
4 Member Release Form for Piedmont Community Health-CARE members
This is the form Piedmont needs for member authorization to discuss member claim information with a third party.