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PIAG Region license # 0747420

Employer Forms

General

• 2013 Member Participation Agreement and Group Information (Form # ER-01)
• 2013 Group Benefits Brochure
• Group Administrative Guidelines (Form # ER-02)
• Section 125 Cafeteria Plan Document (Form # ER-04)
• Section 125 Employee Salary Reduction Form (Form # ER-05)
• Employee Termination/Change Coverage Form
• Employee Declination of Coverage Form
• Change of Address Form
• 2009 HIPAA Notice
• 2010 HSA Plans Administrative Regulations

COBRA information

• An Employee's Guide to Georgia Extension Health Benefits Continuation
• An Employee's Guide to Health Benefits Under COBRA

Employee forms/Documents

Health Insurance Plans

Blue Shield

• Blue Shield - PPO Premier/Enhanced/Base Enrollment/Change Form (Form # EE-BS-03)
• Blue Shield - PPO Value/Simple Savings 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
• Blue Shield Drug Formulary

2013 Blue Shield Summaries of Benefits & Coverage SBC Guide Base PPO 30 Base PPO 40 Base PPO 50 Enhanced PPO 30 Enhanced PPO 35 Enhanced PPO 40 Enhanced PPO 45 Premier PPO 5 Premier PPO 15 Premier PPO 20 Premier PPO 25 Premier PPO 35 Premier PPO 45 Shield Spectrum PPO 750 Value Shield Spectrum PPO 1000 Value Shield Spectrum PPO 1500 Value Shield Spectrum PPO 2500 Value Simple Savings 2500_5000 Simple Savings 3500_7000 Simple Savings 5500_11000
2013 Blue Shield Benefit Summaries Base PPO 30 Base PPO 40 Base PPO 50 Enhanced PPO 30 Enhanced PPO 35 Enhanced PPO 40 Enhanced PPO 45 Premier PPO 5 Premier PPO 15 Premier PPO 20 Premier PPO 25 Premier PPO 35 Premier PPO 45 Shield Spectrum PPO 750 Value Shield Spectrum PPO 1000 Value Shield Spectrum PPO 1500 Value Shield Spectrum PPO 2500 Value Simple Savings 2500_5000 Simple Savings 3500_7000 Simple Savings 5500_11000	2012 Blue Shield Benefit Summaries Active Choice 750 Active Choice 500 PPO Zero Deductible PPO 250 Standard PPO 250 Premier PPO 500 Standard PPO 500 Premier PPO 500 Value PPO 1000 PPO 1000 Value PPO 1500 Value Spectrum PPO 2000 Value PPO 3000 PPO Savings 2250 PPO Savings 2500 Savings QS 4800 Added Advantage POS
2013 Blue Shield Evidence of Coverages Base PPO 30 Base PPO 40 Base PPO 50 Enhanced PPO 30 Enhanced PPO 35 Enhanced PPO 40 Enhanced PPO 45 Premier PPO 5 Premier PPO 15 Premier PPO 20 Premier PPO 25 Premier PPO 35 Premier PPO 45 Shield Spectrum PPO 750 Value Shield Spectrum PPO 1000 Value Shield Spectrum PPO 1500 Value Shield Spectrum PPO 2500 Value Simple Savings 2500_5000 Simple Savings 3500_7000 Simple Savings 5500_11000	2012 Blue Shield Evidence of Coverages Active Choice 750 Active Choice 500 PPO Zero Deductible 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 Spectrum PPO 2000 Value PPO Savings 2250 PPO Savings 2500 Savings QS 4800 Added Advantage POS
Upcoming Plan Changes effective 12/1/12 Active Choice 750 SG to Premier PPO 35 Active Choice 500 SG to Premier PPO 45 PPO Zero Deductible to Premier PPO 5 PPO 250 Standard to Premier PPO 25 PPO 250 Premier to Premier PPO 15 PPO 500 Standard to Premier PPO 35 PPO 500 Premier to Premier PPO 25 PPO 500 Value to Shield Spectrum PPO 750 Value PPO 1000 to Premier PPO 35 PPO 3000 to Enhanced PPO 35 Spectrum PPO 2000 Value to Shield Spectrum PPO 2500 Value PPO Savings 2250 to Simple Savings 2500 PPO Savings 2500 to Simple Savings 3500 Savings QS 4800 to Simple Savings 5500 Added Advantage POS to Premier PPO 25

Kaiser Permanente

• Kaiser - HMO Signature Enrollment/Change Form (Form #EE-KP-02)
• Kaiser - Emergency and Out-of-Area Claim Form (Form #KP-00020797-2-97)

2013 Kaiser Summaries of Benefits & Coverage Signature HMO 20_30 Signature HMO 40_50 Signature HMO 50_55 Signature Ded HMO 750/25 Signature Ded HMO 1000/30 100% Signature Ded HMO 2000/40 90% Signature High Deductible HMO 2000/100%
2013 Kaiser Benefit Summaries Signature HMO 20_30 Signature HMO 40_50 Signature HMO 50_55 Signature Ded HMO 750/25 Signature Ded HMO 1000/30 100% Signature Ded HMO 2000/40 90% Signature High Ded HMO 2000/100%	2012 Kaiser Benefit Summaries Signature HMO 20_30 Signature HMO 40_50 Signature HMO 50_55 Signature Ded HMO 600/25 Signature Ded HMO 1000/30 100% Signature Ded HMO 2000/40 90% Signature High Ded HMO 2000/100%
2012 Kaiser Evidence of Coverage Signature Ded HMO 600_25_100 Signature Ded HMO 1000_30_100 Signature Ded HMO 2000_40_90 Signature High Ded HMO 2000_100 Signature HMO 20_30 Signature HMO 40_50 Signature HMO 50_55	2011 Kaiser Evidence of Coverage Signature Ded HMO 90% Signature Ded HMO 100% Signature HMO 15_25 Signature HMO 20_30 Signature HMO 40_50 Signature HMO 50_55

Custom Plans

• AETNA Small Group Enrollment/Change Form (Form # GR-67834-08(1-08))
• AETNA Medical Claim Form

2013 AETNA Small Group Benefit Summaries POS Open Access 1902 POS Open Access 1903 POS Open Access 1904 POS Open Access 1905 POS Open Access 1913 POS Open Access 1914 SMALL HMO Open Access 701 SMALL HMO Open Access 702 SMALL HMO Open Access 703 SMALL HMO Open Access 704 SMALL HMO Open Access 709A SMALL HMO Open Access 903 SMALL HMO Open Access 905 SMALL HMO Open Access 912 SMALL HMO Open Access 945 SMALL POS Open Access 902

• BCBS Enrollment/Change Form (Form # F-1681.526 Rev. 02/06)
• BCBS RX Mail Order Form

2013 Blue Cross/Blue Shield Benefit Summaries 1201SX PPO 1202SX PPO 1501SX PPO 1506SX PPO 2002SX POS 2003SX POS 2007AX POS 2008AX POS 2502SX POS 2506AX POS 2507AX POS 2510SX POS 2801SX POS 2803AX POS 2804SX POS 3001SX HMO 3002SX HMO 3003 HMO 3004AX HMO 3005AX HMO 3006AX HMO 3082SX HMO 3500SX HMO 3502AX HMO 3503SX HMO 3802AX HMO 3802SX HMO

• 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)

2013 Coventry Benefit Summaries 25_50_1500_100_70 CHOICE_2500_DED_100_60 HMO_15_30_0_DED HMO_20_40_500_80 HMO_20_40_500_100 HMO_20_40_1000_80 HMO_20_40_1500_80 HMO_20_40_1500_100 HMO_25_50_500_80 HMO_25_50_1000_80 HMO_25_50_1500_100 HMO_25_2500_100 POS_15_30_0_100 POS_20_40_500_80 POS_20_40_500_100 POS_20_40_1000_80_60 POS_20_40_2500_100_70 POS_25_50_500_100_70 POS_25_50_1500_80_60 POS_25_50_2500_100_70 POS_40_40_250_100_70 POS_HCR_25_50_500_80_60

Other Plans

Executive Benefit Option

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

Dental

Enrollment/Change forms

• All plans (Form # EE-DN-01)
• Humana custom plans (Form # EE-DN-02)

HIPAA Authorization form for Protected Health Information

• CIGNA Dental

Dental Claim Form

• Humana PPO
• AETNA Dental Claim Form

Dental Plan Benefit Summaries Humana Advantage Plus 1S Humana Advantage Plus 2S Humana Preferred PPO 1 Humana Preferred PPO 2 CIGNA DMO W1-07 CIGNA DMO F1-07

Dental Plan Evidence of Coverage CIGNA W1 CIGNA F1 CIGNA DPO

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 Signature VSP Choice

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

2012 MHN Evidence of Coverage MHN EOC

Life Insurance

Voluntary Term Life

• Group Enrollment form
• Statement of Insurability
• Coverage Benefit Options
• Conversion Form
• Beneficiary Form
• Waiver of Premium
• Proof of Death
• Voluntary Term Life Summary of Plan Description
• Traditional Term Life Summary of Plan Description

Certificates of Insurance VTL 25-250k

Basic Group Life

• Humana Group Life Claim Form
• Humana Group LIfe Beneficiary Form

Certificates of Insurance PICT HumanaLife 4k Cert. Class 8 PICT HumanaLife 5k Cert. Class 7 PICT HumanaLife 6k Cert. Class 6 PICT HumanaLife 8k Cert. Class 5 PICT HumanaLife 10k Cert. Class 4 PICT HumanaLife 15k Cert. Class 3 PICT HumanaLife 25k Cert. Class 2 PICT HumanaLife 50k Cert. Class 1

Health Care Provider Links

MEDICAL
Blue Shield PPO	(888) 235-1765	www.blueshieldca.com
Kaiser Permanente	(404) 261-2590	http://my.kp.org/pibt/index.html
DENTAL
Cigna Dental DPO & DMO	(800) 367-1037	www.cigna.com
HUMANA PPO	(800) 233-4013	www.humanadental.com
HUMANA DMO (Advantage Plus)	(800) 979-4760	www.humanadental.com
VISION
EyeMed Vision Care	(866) 939-3633 option 6	www.eyemedvisioncare.com
VSP Signature & Choice	(800) 877-7195	www.vsp.com
MENTAL HEALTH
Employee Assistant Program EAP	(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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Phone: (323) 728-9500 or 808-9990 for area codes: 213, 310, 619, 714, 818, & 951