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
•
Employee 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).
• Group Termination Notice
This electronic form can be used to notify Piedmont of the Group's intention to terminate coverage.