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

Claim Forms:

Medical: Aetna Medical Claim Form

Dental: Delta Dental Claim Form

Prescription: Express Scripts Claim Form

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

New! Flexible Spending Account: Flex Facts Claim Form

New Jersey Chapter 375:
Coverage for NJ Dependents up 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

Mail completed forms to:

PERMA, Inc. - HIF Billing, 250 Pehle Avenue Saddle Brook NJ 07663, Attn: Holly Cosgrove

Continuation of Coverage for Handicapped Child

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):

The Lance Group Release of Information Authorization

Voluntary Medical Benefits Waiver-

Voluntary Medical Benefits Waiver Form

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