Cinnaminson EBH

Forms

Enrollment Forms:

Medical:

SNJREBF Form and Aetna Medical Enrollment Form

Dental: SNJREBF Form

Prescription: SNJREBF Form

Prescription Mail Order:

Express Scripts Mail Order Form

Express Scripts Mail Order Brochure

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

Medical: Aetna Chapter 375 Instructions, Verification and Enrollment Form

Please note: There will be a cost associated with the addition of any Chapter 375 Dependent to your benefit plan and state law allows carriers to charge up to 102% of the single-plan rate. Most carriers, however, are charging much less: you will need to contact your carrier for the current Chapter 375 Dependent rate. This cost will be billed directly to the dependent.

Prescription: Express Scripts 375 Enrollment Form

Claim Forms:

For Claims Incurred After 7/1/2010-

Medical: Aetna Medical Claim Form
Dental: Delta Dental Claim Form

Prescription: Express Scripts Claim Form

Vision (eyeglasses/contact lenses): Aetna Vision Claim Form & Instructions

For Claims Incurred Before 7/1/2010-

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.

Request for Continuation of Medical Coverage for Disabled Student or Handicapped Child

Handicapped Child Attending Physician's Statement

Other Forms:

Authorization to disclose private health information (HIPAA Release):

Gallagher Benefit Services Release of Information Form

AmeriHealth Release of Information Form

Voluntary Medical Benefits Waiver

Voluntary Medical Benefits Waiver Form

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