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:
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.
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.