Download a Form

If you have any questions about using this website or about these forms, please contact us at: 717-553-1124 or 1-855-408-8503.

Incident Questionnaire (.pdf) 
Use this form if you or a dependent received medical care due to an accident or another party was responsible for your injuries or illness. This information is necessary for us to process your claims.

Coordination of Benefits Questionnaire (.pdf)
Complete this form if you or your dependent have other health coverage in addition to this health plan. This information is needed to determine the order of responsibility in processing you or your dependent’s claims. 

Authorization for Employee Access to Adult Dependent’s Online Health Claim Information (.pdf)
We require this form to be completed if you, the employee, request the ability to review claim information for your spouse and/or dependent child 18 years or older.

Medical Claim Form (.pdf)
If you are submitting a claim for benefits to us, instead of your provider, complete this form and mail it with your medical bill.

Application to Request Coverage Continuation for Disabled Dependent (.pdf)
If you wish to continue health coverage for a dependent child, who is disabled, past your plan’s limiting age, you and your physician will need to complete this form. For more information about your plan’s eligibility requirements, please see your Summary Plan Description.

Member Authorization to Release Claim and Benefit Information (.pdf)
Use this form if you want to authorize the release of your Protected Health Information to another person or organization.

To download these forms, you will need Adobe Acrobat Reader (for .pdf files). If you do not have Adobe software, please visit the following website to download a free version of Adobe Acrobat Reader: