Member Forms

Normally claims are submitted by the Piedmont network provider.  Following that, the member will get a Piedmont statement regarding what was paid out by Piedmont to the provider and advising the member if they have any financial responsibility.  However, if you use an "out of network" provider, or if you are in a situation when you have to pay "up front" for medical services and then need to be reimbursed, you will have to submit one or more of the below forms to Piedmont.  You can download these printable Member Forms by clicking on the following:

• Medical Claim Form 
  This is the Piedmont form to submit when filing a claim for an out-of-network provider, or for reimbursement for advance payment. 
• Prescription Claim Form
  This is the Piedmont form to submit when filing a claim for prescription cost reimbursement.
• Prescription Mail Order Form This is the form you need to submit when requesting a 90-day supply of maintenance medication by mail (don't forget you can also use one of the "walk-in" 90-day supply participating pharmacies).
• College Student Form 
  This form needs to be submitted for all out-of-area covered dependents attending college.
• Additional Services Brochure 
  This is the printable version of the Piedmont Additional Services Brochure, but you may also check out the merchants by going here.