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Enrollment Forms:

Medical Benefits (Non-Medicare) Enrollment

Medicare Supplement Plan Application

Statement of Health Form

Application for Medical Benefits for Adult Children (Under Age 26)

Claim Forms:

Highmark Member Submitted Claim Form(for reimbursement of medical services.)

Highmark Shingles Claim Form(for reimbursement of the Shingles vaccine)

BlueCross BlueShield International Claim Form (for reimbursement of foreign medical care only)

Pharmacy Service Claim Form--Please contact Express Scripts at 1.800.939.3781 or log in to your account at www.express-scripts.com to access member submitted pharmacy claim forms.

Other Health Plan Related Forms:

Domestic Partnership Statement of Financial Interdependence Form

Certification of Domestic Partner as Dependent or Non-Dependent

Protected Health Information Release Form

Copyright© 2018   The Pension Boards-United Church of Christ, Inc.
475 Riverside Drive, Room 1020, New York, NY 10115  •  Phone: 800.642.6543  •  Fax: 212.729.2701 •  E-mail: info@pbucc.org