Employer Forms
Piedmont has provided this section for employers and Group Administrators to access any needed hard copy forms. If you need mulitple copies or a supply of enrollment packets, please contact us directly with your request by phone at 434-947-4463, ext. 204, or by
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
.
Otherwise, 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.
• 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).
• College Student 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.
• LocalSelect POS Enrollment Form
This is the standard POS 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.
• Individual Health Form
This form must be filled out by each employee for groups under 24 people before Piedmont can provide final rates.
• 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.
