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PIAG Region license # 0747420

Employer Forms

General

• 2012 Member Participation Agreement and Group Information (Form # ER-01)
• 2012 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/Waive/Decline Coverage Form (Form # ER-06)
• 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 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
• Blue Shield Drug Formulary

2011 Blue Shield Benefit Summaries Active Choice 750 Active Choice 500 AccessPlus HMO 5 AccessPlus HMO 10 AccessPlus HMO 15 AccessPlus HMO 20 AccessPlus HMO 25 AccessPlus HMO 30 AccessPlus HMO 40 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

2012 Blue Shield Benefit Summaries Active Choice 750 Active Choice 500 AccessPlus HMO 5 AccessPlus HMO 10 AccessPlus HMO 15 AccessPlus HMO 20 AccessPlus HMO 25 AccessPlus HMO 30 AccessPlus HMO 40 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

2010 Blue Shield Evidence of Coverages Active Choice 500 Active Choice 750 POS Advantage HMO 5 HMO 10 HMO 15 HMO 20 HMO 25 HMO 30 HMO 40 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 PPO Zero

2011 Blue Shield Evidence of Coverages Active Choice 750 Active Choice 500 AccessPlus HMO 5 AccessPlus HMO 10 AccessPlus HMO 15 AccessPlus HMO 20 AccessPlus HMO 25 AccessPlus HMO 30 AccessPlus HMO 40 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

Kaiser Permanente

• Kaiser - HMO Signature Enrollment/Change Form (Form #EE-KP-02)

2011 Kaiser Benefit Summaries Signature Ded HMO 90% Signature Ded HMO 100% Signature HMO 15_25 Signature HMO 20_30 Signature HMO 40_50 Signature HMO 50_55	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%
2010 Kaiser Evidence of Coverage HMO 15/25 Classic HMO 20/30 Signature Deductible HMO 1500/30 Deductible HMO 600/25 Classic POS High 500 POS Low 1000	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))

2011 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

2011 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)

2011 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

• United Healthcare Enrollment/Change Form (6-19 emp.)
• United Healthcare Enrollment/Change Form (20-99 emp.)

2011 United Healthcare Benefit Summaries Choice Plus 25/500/90% Plan G1D RX 10/30/50/100 Plan 04F

Other Plans

Executive Benefit Option

• Employer Brochure (Form # ER-EX-01)
• 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 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

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

• Summary of Plan Description
• Waiver of Premium
• Proof of Death
• Beneficiary Form
• Conversion Form
• Death Benefits

Certificates of Insurance Basic Group Life GA 4k-10k

Health Care Provider Links

MEDICAL
AETNA	(800) 323-9930	www.aetna.com
AETNA RX Home Delivery	(866) 612-3862	www.aetnarxhomedelivery.com
Blue Shield HMO & PPO	(888) 235-1765	www.blueshieldca.com
Cigna Healthcare	(800) 244-6224	www.cigna.com
Kaiser Permanente	(404) 261-2590	http://my.kp.org/pibt/index.html
DENTAL
Cigna Dental	(800) 367-1037	www.cigna.com
HUMANA DPO	(800)233-4013	www.humanadental.com
HUMANA DMO	(800) 979-4760	www.humanadental.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

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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