Forms and Documents for Producers

All forms are in Adobe Acrobat format.

Directories:

• Contact Phone List

General:

• Broker Commissions Authorization/Agreement for Direct Deposit
• Commercial Table of Commissions
• Presbyterian Senior Care Table of Commission Rates
• How to Quote and Enroll a  Group with Presbyterian

Guidelines: 

• Field Underwriting Guidelines (Group)

Forms:

• HIPAA - General Release of Information Form: Member/Subscriber
• My Care Unique Service Reimbursement Form
• PresMetro Unique Service Reimbursement Form
• Member Termination/Change Form (for groups only)
• Medicare Sales Appointment Confirmation Form

Questions and Answers:

• Commonly asked questions about non-par providers (R&C, DDs etc)
• 4-Tier Prescription Drug commonly asked questions

Presbyterian Group Benefit Information:
Benefit Brief

• Value Care Plans (Group size 2-50 HMO)
• Smart Care Plans (Group size 2-50 HMO)
• PresElect Plans (Group size 2-50 PPO)
• Vantage Care Pans (Group sizes 2-50 and 51+ HDHP, qualified HSA plans)
• Custom Care Plans (Group size 51+ HMO)
• Smart Care Plans (Group size 51+ HMO)
• Preferred Care Plans (Group size 51+ PPO)

Presbyterian Group Benefit Information:
Archived Benefit Brief (currently being retired)

• Preferred Care Plans (Group size 2-50 PPO)
• Advantage Care Plans (Group size 2-50 HDHP, qualified HSA plans)
• Advantage Care Plans (Group size 51+ HDHP, qualified HSA plans)

        For POS plans, please contact your Account Manager or Account Executive to obtain more information

Benefit Summaries by Plan Design - Small Group size 2-50
Benefit Summaries by Plan Design - Large Group size 51+

Riders

• Prescription Riders HMO (Group size 51+)
• Prescription Riders PPO (Group size 51+)
• Benefit Summaries by Prescription Rider Design
• Benefit Summaries by Substance Abuse Rider Design (Group size 51+)  
• VSP Vision Riders (Group size 2+)

Forms for Quoting a Group with Presbyterian

• Rate Request Form
• Census Form
• UMAF Medical Assessment Form/English
• UMAF Medical Assessment Form/Spanish 

Forms for Enrolling a Group with Presbyterian

• Enrollment Checklist 
• Employer Group Information Sheet 
• Employee Action Form PIC/PHP (enrollment /change /waiver) 
• Spanish Employee Action Form PIC/PHP (enrollment /change /waiver) 
• PHP Individual Assessment Form 
• PIC Individual Assessment Form
• Exhibit B, Bank Draft Authorization (Required for Groups 2-9) 
• PEO/Leased Employee Verification Form 
• Transition of Care Form

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Individual Plans:

More information about Presbyterian's Individual Plans 

Individual Enrollment Application

Active Plan Rate Sheets

• Individual and Family Plan
• Individual and Family Plan - Child Only

Non-Active Plan Rate Sheets  - (not available for sale)

• Select Rate
• Classic Rate
• Savvy100 Rate 
• Classic for Kids
• PresMetro Plus with Dental Rate 
• PresSolo Rate
• Advantage Care Rate 
• Individual Care Rate

Benefits

• Individual and Family Plan Benefit Brief

• Select Plan Benefit Brief (no longer available for new sale)
• Classic Plan Benefit Brief (no longer available for new sale)
• Savvy100 Plan Benefit Brief (no longer available for new sale)
• Classic for Kids Plan Benefit Brief (no longer available for new sale)
• Delta Dental (Select, Classic, Savvy100 Plans) (no longer available for new sale)
• VSP (Select Plans) (no longer available for new sale)
• PresMetro Plan Benefit Brief (no longer available for new sale)
• PresSolo Plan Benefit Brief (no longer available for new sale)
• Advantage Care Plan Benefit Brief (no longer available for new sale)
   

Individual Plan Member Forms

• Individual Member Add/Move Dependent Form
• Individual Member Termination Form
• PresMetro Unique Services Reimbursement Form
• PresSolo Unique Services Reimbursement Form
• Select Plan Unique Services Reimbursement Form
• Presbyterian HSA Authorization Savvy100 Form

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Health Savings Account Information

• Presbyterian HSA Authorization Savvy100 Form
• Vantage HSA Authorization Form
• Health Equity HSA Fact Sheet