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Forms

Enrollment  Forms:

Medical
 
Dental:  SNJREBF Form
 
Prescription:  SNJREBF Form

Prescription Mail Order:
 
 
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-
 
 
 
For Claims Incurred Before 7/1/2010-
 
Medical: 
Prescription:    Benecard Claim 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. 

 
 

Other Forms:

Authorization to disclose private health information (HIPAA Release):
 
 
 
 
Voluntary Medical Benefits Waiver
 
 
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