Forms
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Claim Forms
Dental Claim Form
If your plan includes dental coverage, this form is to be completed by the employee, provider, or employer for payment of claims. Attach itemized statements, including date, type and place of service, fees, and signature of provider or representative.
Disability Proof of Loss Form*
If your plan includes dental coverage, this form is to be completed by the employee, provider, or employer for payment of claims. Attach itemized statements, including date, type and place of service, fees, and signature of provider or representative.
Disability Proof of Loss Form*
Eligibility Forms
HIPAA Privacy Forms
Please submit completed forms to:
Corporate Privacy Office
Planned Administrators, Inc.
P.O. Box 6927
Columbia, SC 29260
Corporate Privacy Office
Planned Administrators, Inc.
P.O. Box 6927
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 Company
NOTICE OF PRIVACY PRACTICES - 4 EVER Life Insurance Company
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 Company
NOTICE OF PRIVACY PRACTICES - 4 EVER Life Insurance Company
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
* 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.