Agent Forms

COBRA

• Model ARP General Notice

• COBRA Continuation Coverage Election Notice

• Notice of Early Termination COBRA Coverage

• PA Mini-COBRA Notice Template

FBP Business Services Forms

• Pre-Authorized ACH Debit Form

• IBC Broker of Record Form

• IBC Employer Authorization Form

Independence Blue Cross Forms

• Census for New Business

• College Tuition Benefit

• CTB Administration Guide

• CTB Employer FAQ

• CTB Member FAQ

• Claim Reimbursement Forms

• Point of Service Claim Form

• Personal Choice Out-of-Network Claim Form

• IBC Waiver Form

• Guest Membership Application

• Application to Continue Coverage for Handicapped Dependent Child

• PA Dependent to 30 - Enrollment Form

• Prescription Drug Reimbursement Form

• Prescription Mail Service Order Form

• Influenza Reimbursement Form

• IBC / KHPE Medicare Advantage

• Personal Choice 65 Disenrollment Form

• Keystone 65 Disenrollment Form

• Select Option Disenrollment Form

• AmeriHealth 65 Disenrollment Form

• AmeriHealth Advantage Disenrollment Form

• AmeriHealth Rx Disenrollment Form

United Concordia

• Claim Form

• Dependent Certification Form