Forms

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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 (Use this form if Rx group: ECPAI is on your ID card.)
Prescription Drug Claim Form (Use this form if Rx group: ECFDRX is on your ID card.) If your Medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to Caremark by the pharmacy, use this form to submit for payment.
If your Medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the Medical Claim form located in the Forms section of this web site.
Please see your Summary Plan Description if you have questions as to which plan is associated with your group.
Short-Term Disability / Proof of Loss 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.)
 
Form 32 - Complaint Form (BCS Insurance Co.)
 

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