PIAG Region license # 0747420

Employer Forms

General

• 2008 PIAG Member Participation Agreement and Group Information (Form # ER-01.2)
• 2008 Group Benefits Brochure
• Group Administrative Guidelines (Form # ER-02g)
• Supply Order Form (Form # ER-03)
• Cafeteria Plan Document
• Section 125 Employee Salary Reduction Form (Form # ER-05)
• Employee Termination/Waive/Decline Coverage Form (Form # ER-06)
• Change of Address Form

Employee forms/Documents

Health Insurance Plans
AETNA

• AETNA - HMO Enrollment/Change Form (Form # GA R-POD1)
• AETNA - POS Enrollment/Change Form (Form # GA R-POD2)
• AETNA RX Home Delivery Brochure
• AETNA RX Home Delivery Order Form
• AETNA Medical Claim Form
• AETNA RX Claim Form
• AETNA (PHI) Protected Health Information HIPAA Authorization Form

07 AETNA Benefit Summaries HMO 25 HMO 40 POS 1000

07 AETNA Evidence of Coverage HMO POS

Blue Shield

• Blue Shield - PPO Enrollment/Change Form (Form # EE-BS-03)
• Blue Shield - Active Choice Enrollment/Change Form (Form # EE-BS-04)
• Blue Shield - Subscribers Statement of Claim
• Blue Shield - Prescription Drug Direct Reimbursement Form
• Blue Shield International Claim Form
• Blue Shield (PHI) Protected Health Information HIPAA Authorization Form
• Blue Shield RX Mail-order Program

07 Blue Shield Benefit Summaries Active Choice 750 Active Choice 500 PPO Zero PPO 250 Standard PPO 250 Premier PPO 500 Standard PPO 500 Premier PPO 500 Value PPO 1000 PPO 1000 Value PPO 1500 PPO 3000 PPO 2250 PPO 2600

08 Blue Shield Benefit Summaries Active Choice 750 Active Choice 500 PPO Zero PPO 250 Standard PPO 250 Premier PPO 500 Standard PPO 500 Premier PPO 500 Value PPO 1000 PPO 1000 Value PPO 1500 Value PPO 3000 PPO 2250 PPO 2500

07 Blue Shield Evidence of Coverages PPO Zero Deductible Active Choice 500 Active Choice 500 RX Active Choice 750 Active Choice 750 RX PPO 250 Premier PPO 250 Premier RX PPO 250 Standard PPO 250 Standard RX PPO 500 Premier PPO 500 Premier RX PPO 500 Standard PPO 500 Standard RX PPO 500 Value PPO 500 Value RX PPO 1000 PPO 1000 RX PPO 1000 Value PPO 1000 Value RX PPO 1500 Value PPO 1500 Value RX PPO 2250 PPO 2600 PPO 3000 PPO 3000 RX

08 Blue Shield Evidence of Coverages PPO Zero Deductible Active Choice 500 Active Choice 750 PPO 250 Premier PPO 250 Standard PPO 500 Premier PPO 500 Standard PPO 500 Value PPO 1000 PPO 1000 Value PPO 1500 Value PPO SavingsPlan 2250 PPO SavingsPlan 2500 PPO 3000

CIGNA

• CIGNA - HMO Enrollment/Change Form (Form # EE-CG-02)
• CIGNA (PHI) Protected Health Information HIPAA Authorization Form
• CIGNA RX Mail-order Program

07 CIGNA Benefit Summaries HMO 15 HMO 30	08 CIGNA Benefit Summaries HMO 20 HMO 30
07 CIGNA Evidence of Coverage HMO 15 HMO 30	08 CIGNA Evidence of Coverage HMO 20 HMO 30

Custom Plans

• AETNA Enrollment/Change Form (Form # GR-67834-8 Rev. 08/06)
• BCBS Enrollment/Change Form (Form # F-1681.526 Rev. 02/06)

08 Blue Cross/Blue Shield Benefit Summaries HMO Plan 302 HMO Plan 322 HMO Plan 3000SX HMO Plan 3001SX HMO Plan 3005AX HMO Plan 3500S POS Plan Open Access POS Plan

• Coventry Enrollment/Change Form (2-19 emp.) (Form # CHCGA.EF.SM.02-07)
• Coventry Enrollment/Change Form (20-99 emp.) (Form # CHCGA.EF.20-99.02-07)
• Coventry Enrollment/Change Form (51+ emp.) (Form # CHCGA.EF.51+.07-06)
• Coventry Waiver (Form # CHCH 1233-33)
• United Healthcare Enrollment/Change Form (6-19 emp.)
• United Healthcare Enrollment/Change Form (20-99 emp.)

08 United Healthcare Benefit Summaries Choice Plus 25/500/90% Plan G1D RX 10/30/50/100 Plan 04F

Other Plans

• Executive Option Employer Brochure (Form # ER-EX-01)
• Executive Benefit Summary Plan Description
• Employer Executive Option New Group Summary and Application (Form # ER-EX-02)
• Employee Executive Option Enrollment/Change Form (Form # ER-EX-03)
• Executive Option Claim Form

Dental

• Dental Enrollment/Change Form for all plans (Form # EE-D-01)
• Dental Enrollment/Change Form for Humana
• CIGNA Dental (PHI) Protected Health Information HIPAA Authorization Form
• AETNA Dental Claim Form

Dental Plan Benefit Summaries AETNA DMO 51 AETNA DMO 58 AETNA Custom Dental Plan FOC3 no Ortho AETNA Custom Dental Plan FOC3 Ortho AETNA PPO 50 AETNA PPO 100 CIGNA DMO F1 CIGNA DMO W1 CIGNA PPO

Vision

• Vision Enrollment/Change Form (Form # EE-VS-01)
• Vision Claim Form
• EyeMed Out-of-Network Claim Form
• VSP Out-of-Network Claim Form
• VSP (PHI) Protected Health Information HIPAA Authorization Form

Vision Plans Benefit Summaries EyeMed VSP I VSP II

Mental Health

• Mental Health Enrollment/Change Form for all plans (Form # EE-MH-01)
• Mental Health (PHI) Protected Health Information HIPAA Authorization Form

Mental Health Plans Benefit Summaries Employee Assistance Program Comprehensive

08 MHN Evidence of Coverage 08 MHN EOC

Life Insurance

• Voluntary Term Life Group Enrollment Form
• Voluntary Term Life Statement of Insurability
• Voluntary Term Life Coverage Benefit Options
• Voluntary Term Life Beneficiary Form


• Voluntary Term Life Conversion Form
• Voluntary/Traditional Life Waiver of Premium
• Voluntary/Traditional Life Proof of Death
• Voluntary Term Life Summary of Plan Description


• Basic Group Life Summary of Plan Description
• Basic Group Life Waiver of Premium
• Basic Group Life Proof of Death
• Basic Group Life Beneficiary Form

Certificates of Insurance VTL 25-250k

Miscellaneous Forms

• Full Time Student Certification Form (Form # EE-ST-01)

Health Care Provider Links

MEDICAL
Blue Shield HMO & PPO	(888) 235-1765	www.blueshieldca.com
Cigna Healthcare	(800) 244-6224	www.cigna.com
AETNA	(800) 323-9930	www.aetna.com
AETNA RX Home Delivery	(866) 612-3862	www.aetnarxhomedelivery.com
DENTAL
AETNA Dental	(800) 323-9930	www.aetna.com
Cigna Dental	(800) 367-1037	www.cigna.com
VISION
EyeMed Vision Care	(866) 939-3633 option 6	www.eyemedvisioncare.com
VSP I & VSP II	(800) 877-7195	www.vsp.com
MENTAL HEALTH
Employee Assistant Program EAP	(800) 777-9355	www.members.mhn.com
Comprehensive Mental Health	(800) 777-9355	www.members.mhn.com

Other Regions

Forms are tailored by region:

For an evaluation of your insurance coverage today, please call the Insurance Department at 323-728-9500.

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