EssentialCare - a limited benefit health insurance product

Forms

Adobe Reader required to view forms. If you do not have Adobe Reader, click here for a free download.

If you need assistance completing any forms or have any questions, please call HospitalityCare customer service at 1-888-583-3057. Representatives are available Monday through Friday, 8:30 a.m. to 8:00 p.m. Eastern Time.

Claim Forms

Dental Claim Form

Eye Exam Claim Form

EyeMed Out-of-Network Claim Form

Medical Claim Form

Prescription Drug Claim Form

Short-Term Disability / Proof of Loss Claim Form*

Term Life / Accidental Death Claim Form*

Eligibility Forms

Missed Premium Direct Payment Form

Termination / Involuntary Loss of Coverage Form

HIPAA Forms

Please submit completed forms to:

Corporate Privacy Office
Planned Administrators, Inc.
P.O. Box 6702
Columbia, SC 29260

Authorized Representative Form (English) Protected Health Information (PHI) is not released to anyone other than those specifically authorized by the insured using this form.

Formulario de Representante Autorizado (Español) La Información Protegida de la Salud (PHI) no es liberada a nadie de otra manera que esos específicamente autorizado por el utilizar asegurado esta forma.

NOTICE OF PRIVACY PRACTICES (BCS Insurance Co.)

NOTICE OF PRIVACY PRACTICES (Companion Life)

Form 3 - Authorization Form
Form 4 - Authorization for Marketing
Form 21 - Access Request
Form 22 - Amendment Request
Form 23 - Disclosure Accounting Request
Form 25 - Restriction Request
Form 27 - Confidential Communications Request

Form 32 - Complaint Form (BCS Insurance Co.)

Form 32 - Complaint Form (Companion Life)

*Underwriter name for Short-Term Disability and Term Life/AD&D insurance has changed from BCS Life insurance Company to 4 Ever Life Insurance Company.