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.

       • 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).

• 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.

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