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.
• Group Amendment Form
This electronic form is to be used if the Group wishes to update Group Contact, Authorized Persons, Mailing and/or Physical Address, Eligibility and/or Term Period.