Coordination of Benefits (COB) Questionnaire Form

Notify the Plan of other insurance coverage in order to determine the order of benefits/coverage. You can also submit this form by logging in to your Benefits Manager, clicking on 'Go Paperless' from the menu and selecting 'Forms and Letters.'

Medical Claim Form

Submit medical care claims to the Plan. Please be advised that no rights under the Plan, including but not limited to the right to receive any benefit or any right to pursue a Claim or cause of action, are assignable to another party. For more information see the "Authorized Representatives” section of the SPD.

Delta Dental Claim Form

Submit dental care claims if you are treated by a dentist who is not a member of Delta Dental. See instructions on how to submit this form.

Express Scripts Rx Claim Form

Get reimbursed for prescription drug claims. Please use the Medical Claim Form if you are submitting prescription receipts under secondary coverage.

Beacon Health Options Mental Health/Substance Abuse Treatment Claim Form

Submit this form for mental health/substance abuse treatment claims. You may also fill out and submit an online form on the Achieve Solutions website.

Health Insurance Claim Form

Health care providers can submit this form for services provided to patients.