EMPLOYEE FORMS

In addition to making official forms available in focused areas of the benefit directory, all forms offered are available here to expedite your retrieval of those forms. Download the Acrobat Reader to your computer to view forms. CLICK THE ADOBE LINK ON THE BOTTOM OF THIS PAGE.

New forms will be added and updated as appropriate.

MEDICAL

Cigna Flyer Instructions for Finding a Doctor
Cigna One Guide Benefits Overview without Pharmacy Customer Flyer

Approved Prescription List (ESI Basic Formulary)
ESI Standard Plus Generic Preventive Medications
ESI – ACA Drug List Standard Offering

Copy of ESI ACA Preventive Meds
Medical Claim Form
Cigna Total Behavioral Health Happify Customer Flyer
Answers by Cigna for Amazon Alexa Customer Flyer
iPrevail Customer Flyer
Heathly Babies Cigna Maternity Healthy Start Brochure
Healthy Rewards Healthy Choices Healthy Discounts Customer Flyer

DENTAL

Dental Claim Form
UNUM Dental Info
High Plan Benefit Summary
Low Plan Benefit Summary

VISION

Community Eye Claim Form
Summary of Vision Benefit Coverage

DISABILITY

UNUM Telephonic Claims Submission – FMLA-STD-LTD
STD/LTD Document Information
Summary of LTD/STD Benefits Certification Document
Unum Request of Change Form
Revised Medical Release

GROUP TERM LIFE / AD&D

Enrollment Form
Conversion Form
Evidence of Insurability Form
Portability Coverage Form

Benefit Election Form for Accident Insurance & Specified Disease
Life Insurance Claim Form

ACCIDENT INSURANCE

Flyer on Accident Insurance
Cancel-Change Form Voluntary Benefits
Accident and Critical Illness Enrollment Form
Benefit Election Form for Accident Insurance & Specified Disease
Accident Claim Form
Wellness Flyer
Group Accident All Employees Booklet

CRITICAL ILLNESS INSURANCE

Critical Illness Flyer
Critical Illness Claim Form
Wellness Flyer
Cancel-Change Form Voluntary Benefits
Accident and Critical Illness Enrollment Form
Benefit Election Form for Accident Insurance & Specified Disease

HOSPITAL INDEMNITY

Hospital Insurance Flyer
Cancel-Change Form Voluntary Benefits
Hospital Indemnity Claim Form
Wellness Flyer
Group_Hospital_Confinement_Indemnity_All_Employees_Booklet

FMLA

UNUM Telephonic Claims Submission – FMLA-STD-LTD
Employee Guide to FMLA
Revised Medical Release

MILEAGE REIMBURSEMENT

Piedmont Health Travel Policy
Check Request Form
Mileage Grid between Centers
Travel Report for Printing  (xls)
Travel Expense Report – Fillable  (xls)

CONTINUING EDUCATION

Check Request Form

EAP

EAP Employee Flyer

PIEDMONT HEALTH EMPLOYEE FORMS

PEER Program Resource Guide
PEER Program Veteran Employee
PEER Program Application
Travel Expense Report
Internal Transfer and Advancement Program (ITAP) Form
PHS, Inc. Check Request Form
Staffing Requisition

 

Other Resources

The Piedmont Healthcare Services HR Department can be reached at hrteam@piedmonthealth.org

919-537-7487 – Office
919-537-0469 – FAX

 

 

HUMAN RESOURCES

(Office) 919-537-7503
(Fax) 919-537-0469
hrteam@piedmonthealth.org

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