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Marketplace Premium Payment 1-888-518-7597
Individual & Group Coverage: (800) 400-PCHP
Medicare Advantage: (877) 210-1719
TTY: 711

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.