Cinnaminson EBH

Forms

Following are downloadable forms provided for your convenience (in PDF format unless specified otherwise):

Claim Forms:

Medical: AmeriHealth Medical Claim Form

AmeriHealth Copayment Reimbursement Form

Dental: Horizon Healthcare Dental Claim Form

Prescription: Benecard Claim Form

Vision: Davis Vision Claim Form

AmeriHealth- Prior Carrier Deductible Credit Form

If under a previous plan you incurred expenses that were credited toward your annual deductible in the calendar year or benefit period in which your group became effective, you can receive deductible credit toward your new policy with AmeriHealth.

Mail Order Pharmacy Form:

Benecard Mail Service Order Form

Enrollment Forms:

Medical: AmeriHealth Medical Enrollment Form
Dental: Horizon Healthcare Dental Enrollment Form
Prescription: Benecard Enrollment Form

Chapter 375, New Jersey Chapter 375:
Coverage for NJ Dependents to Age 31

Medical: AmeriHealth Chapter 375 Enrollment Form

AmeriHealth Chapter 375 Instructions

AmeriHealth Chapter 375 Verification

Please note: There will be a cost associated with the addition of any Chapter 375 Dependent to your benefit plan. This additional cost will be between 65% and 70% of the employee-only rate of your chosen plan. This cost will be billed directly to the dependent. The first month's payment is required with submission of the application. Please check with your Benefits Office to obtain the exact amount for the first month's premium.

Prescription: Benecard Chapter 375 Prescription Enrollment Form

Other Forms:

Authorization to disclose private health information (HIPAA Release):

Health Advocate Release of Information Form

The Lance Group Release of Information Form

AmeriHealth Release of Information Form

Voluntary Medical Benefits Waiver

Voluntary Medical Benefits Waiver Form

Incentive Payment Form

Cinnaminson Township Incentive Payment Form

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