Cover Sheet
Form Name	Form Purpose
Health/Disability Insurance Change Form Personal Choice, Keystone Health Plan East, Disability	Use this data form as a cover sheet to submit additions, changes or deletions of health and/or disability insurance coverages.
Enrollment
Form Name	Form Purpose
Application/Change Form Personal Choice	Submit additions or changes to enrollment information for a member
Application/Change Form Keystone Health Plan East	Submit additions or changes to enrollment information for a member
Enrollment Report Personal Choice	Submit additions, changes, or removals to current enrollment information for group coverage
Enrollment Report Keystone Health Plan East	Submit additions, changes, or removals to current enrollment information for group coverage
Student Verification Form Personal Choice	Submit to verify eligibility for coverage as a full- time student
Student Verification Form Keystone Health Plan East	Submit to verify eligibility for coverage as a full- time student
Dependent Certification Form Delta Dental	Submit to verify eligibility for coverage as a dependent
Handicapped Child Application Personal Choice, Keystone Health Plan East	Submit application for coverage of overage, handicapped children
Claims
Form Name	Form Purpose
Out of Network Personal Choice Claim Form Personal Choice	Submit claims for services received by an out-of- network provider
International Claim Form Blue Card	Submit claims for services received by an out-of- network provider internationally
Prescription Drug Claim Form Freestanding, Personal Choice Domestic or International	Submit claims for prescription drugs when an ID Card was not accepted or available
Davis Vision Claim Form Personal Choice	Submit claims for glasses, contact lenses, and office visits for vision care practitioners
Rider Claim Form Personal Choice, Keystone Health Plan East	Submit claims for co-pay rider and mental health rider
Delta Dental Claim Form Personal Choice, Keystone Health Plan East	Submit dental claims
Misc.
Form Name	Form Purpose
HIPAA Authorization Form Personal Choice, Keystone Health Plan East	Form authorizing your health plan carrier or HMO to release your health information to another party
Select Drug Questions and Answers Personal Choice, Keystone Health Plan East	View frequently asked questions and answers about Select Drug benefits
Select Drug Formulary Personal Choice, Keystone Health Plan East	View a listing of which drugs are covered as generic and brand formulary drugs.
Procedures Supporting Safe Prescribing Personal Choice, Keystone Health Plan East	View a listing of mandatory practices that help protect you when receiving prescription drugs
Prescription Mail Order Form Personal Choice, Keystone Health Plan East	Caremark (Mail order Pharmacy Benefit source for IBC for new prescriptions should be mailed to: Caremark P.O. Box 1330 Pittsburgh, PA 15230-9906
HMO Member Disclosure Keystone Health Plan East	Pre-certification requirements and summary of member rights under their health plan