Employer Forms

Piedmont has provided this section for employers and Group Administrators to access any needed hard copy forms.

You can download printable forms by clicking on the following: 

Member enrollment / change forms

• Centra Community HMO Enrollment / Change Form 
This form can be used to make changes to a member's eligibility - enrollment, change or termination.

 • Virginia Expanded PPO Enrollment / Change Form
This form can be used to make changes to a member's eligibility - enrollment, change or termination.

• 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.

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

• 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).

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

• COBRA Enrollment / Re-enrollment Form
This electronic form must be submitted to both enroll and continue in the COBRA administration plan.

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