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Member Downloadable Forms

Appeals

Dental Claim Form

Forms and information members ​need to appeal a claims decision
​Employees fill out this form for a dental claim
Employee
Change Request Form

Allows an employee to change their name, take dependents off coverage, change beneficiaries or change class of insurance

All States - COBRA
(including California with 20
or more employees)


COBRA guide and various forms
Standard Life and Accident
Insurance Company


Limited benefit claim form
Prescription Drug Plan Forms
Mail order forms, claims forms and more


If you are unable to find what you're looking for, please contact Allied Client Services.
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  • Home
  • Employers
    • Self-Service Login
    • Prescription Benefits
    • Lab Program
    • Abenity Discounts
    • Employer Resources >
      • Freedom Hybrid - Employer Resources
      • HSA Freedom Hybrid - Employer Resources
      • Freedom Traditional - Employer Resources
      • Cost Saver Plan - Employer Resources
      • PPO - Employer Resources
      • Freedom Essentials - Employer Resources
      • MEC - Employer Resources
      • Apex MEC - Employer Resources
      • Community Health Plan - Employer Resources
      • Prime-Fundamental Care - Employer Resources
      • Vault PPO - Employer Resources
      • Vault RBP - Employer Resources
    • EBA Newsletter
  • Members
    • Member Resources
    • HealthCare Assistant
    • HealthChoices
    • Self-Service Login
    • Find A Provider
    • Prescription Benefits
    • Telehealth
    • Lab Program
    • Abenity Discounts
    • Member Download Forms >
      • Appeals
    • Member FAQs
  • Agents
    • Agent Edge
    • Plans >
      • Level Funding >
        • Freedom Plan >
          • Hybrid
          • Traditional
          • Essentials
        • PPO
        • Cost Saver Plan
        • Preventive Minimum Essential Coverage
        • Direct Primary Care >
          • DPC Directory
      • Dental Design
      • Pivot Health Individual Plans >
        • Short Term Medical
        • Fixed Benefit
        • Brilliant Dental
      • Premium Only Plan
    • Self-Service Login
    • Download Forms - Agents
    • Product Availability
    • Training Webinars
    • Agent FAQs
  • Provider
    • Provider Verification
    • DPC & Benefit Plans
  • About Us
    • History
    • Testimonials
    • Blog
    • Newsroom >
      • Allied Logos
  • Contact Us