Piedmont Customer Service
(434) 947-4463, (800) 400-PCHP

Individual Marketplace Forms

diamond    Primary Care Physician Designation Form

diamond    Prescription Reimbursement Claim Form

diamond    HIPAA Release Form  - Print Version

diamond    HIPAA Release Form  - Electronic Docusign Version

diamond    Transition of Care Request Form

diamond    Medical Claim Form

diamond    Non-Formulary Exceptions Request Form

diamond    Appointment of Representative Form

diamond    Grievance Form
This fillable form is used by members to file a Grievance. This form is for traditional printing and mailing. For most efficient processing of your Grievance, we recommend filing it electronically through our member portal by clicking here.

diamond    Appeal Request Form
This form is for traditional printing and mailing. For most efficient processing of your Appeal, we recommend filing it electronically through our member portal by clicking here.