Individual Plan Commonly Needed Forms

If you are a current Individual Plan member, and you want to make a change on your policy, please complete the following Add/Change Form. Please complete this form when changing your address, adding a newborn, newly-adopted child or a child for whom a Subcsriber becomes a legal guardian within 31 days of birth, date of placement or the court order granting guardianship.  You may also use this form to terminate your policy or a dependent on your ploicy.

• Add/Change Form

If you wish to add a dependent to your policy you must complete and submit a Medical Questionnaire with the Add/Change Form. You do not need to complete the Medical Questionnaire for newborns added within 31 days of birth.

• Medical Questionnaire

Presbyterian Member Services is the best way to find more information about your healthcare coverage. Our Member Services staff will answer all your questions promptly.

• E-mail/More Info

These forms are in Adobe Acrobat (.pdf) format. Get the Acrobat reader here.

• Member/Subscriber Claim Form
• Injury Questionnaire Form
• Level I Procedural Appeal Form
• Grievance Form
• PresMetro Unique Services Reimbursement Form
• PresSolo Unique Services Reimbursement Form