Premise New Patient Packet

Premise Travel Medicine Questionnaire

Premise Biometric Patient Forms

Adoption Assistance Reimbursement Form

Surrogacy Benefit Reimbursement Form

Fidelity Reimbursement Request Form (for FSA, DCFSA, and HRA)

Appeals – First Level

Administrative Issues

Dental

Disability

Pilot Long Term Disability

Medical Necessity or Infertility (BCBS)

Medical Necessity or Infertility (UHC)

Medical Necessity or Infertility (UMR)

Plan Exclusions (BCBS)

Plan Exclusions (UHC)

Prescription Drugs

Rehabilitative Services (BCBS)

Rehabilitative Services (UHC)

Usual and Prevailing Fee Allowance (BCBS)

Usual and Prevailing Fee Allowance (UHC)

Appeals – Second Level

Administrative Issues

Dental

Disability

Pilot Long Term Disability

Medical Necessity or Infertility (BCBS)

Medical Necessity or Infertility (UHC)

Medical Necessity or Infertility (UMR)

Plan Exclusions

Prescription Drugs

Rehabilitative Services (BCBS)

Rehabilitative Services (UHC)

Usual and Prevailing Fee Allowance (BCBS)

Usual and Prevailing Fee Allowance (UHC)

Disability Claim Form

Post Pregnancy Maternity Short Term Disability Plan Form

Disability Enrollment Form

Disability Direct Deposit Form

Pilots

Disability Coverage (Pilot LTD), First Level Appeal

Long Term Disability Claim Form

Statement of Health – MetLife

American Airlines Medical Plans (PDF)

US Airways Medical Plans (PDF)

Common Law Marriage Recognition Request

Disabled Dependent

Declaration of Domestic Partnership

Medical

DFW ConnectedCare Claim Form (including Doula services)

Blue Cross Blue Shield Claim Form

Blue Cross Blue Shield Doula Claim Form

UMR Claim Form (including Doula services)

UHC Claim Form

UHC Medicare Advantage Claim Form

Dental

Dental Claim Form

Vision

EyeMed Out-of-Network Claim Form

Prescription

Prescription Reimbursement Claim Form

BCBS Medicare Part D Claim Form

UHC Medicare Part D Claim Form

AD&D

Accidental Death Claim Form

Accidental Dismemberment Claim Form

Conversion Information and Form

Flexible Spending Account

Dependent Care FSA Stop Deductions

How to Submit Manual Claims

Prescription Drug

BCBS Medicare Part D Claim Form

UHC Medicare Part D Claim Form

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA Authorization Form

HIPAA Complaint Form

HIPAA Policy

Medicare Crossover Enrollment

BCBS: Contact Customer Service

UHC: Medicare Crossover Enrollment Form

Medicare Part D Form

Notice of Creditable Coverage

BCBS Medicare Part D Claim Form

UHC Medicare Part D Claim Form

Transition of Care

Medical Transition of Care Form

Life Insurance

Life Insurance Portable Coverage

Proof of Good Health – MetLife

American Airlines Medical Plans (PDF)

US Airways Medical Plans (PDF)

AD&D

Accidental Death Claim Form

Accidental Dismemberment Claim Form

Conversion Information and Form

Secure Travel Protection

Death Benefits/Accelerated Option

Death Benefit Accelerated Claim Form

Children’s Health Insurance Program (CHIP)

COBRA General Notices of Continuation of Coverage Rights

Health Insurance Marketplace Notice

Notice of Creditable Coverage 

Notice of Creditable Coverage – 65 and Older

Notice of Creditable Coverage – Under 65

Women’s Health & Cancer Rights Act

The Transparency in Coverage (TiC) Final Rules require group health plans to post in-network and out-of-network machine readable files (MRF) with pricing information on a public website.  Following are the MRFs for the self-funded American Airlines medical plans.

Blue Cross/Blue Shield

UMR

DFW ConnectedCare (choose Preferred_HMO_INN)

SurgeryPlus