Individual & Group Coverage: (800) 400-PCHP
TTY: 711

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.