Employer Commonly Used Forms

Forms to enroll a new employee, make changes to an existing employee’s benefit coverage, and terminate an employee’s benefit coverage:

• UPMC Health Plan/UPMC Health Network Enrollment Form
  
• UPMC Health Plan Membership
  Termination Form
  

Other Forms

Listed below are other forms that may assist you in the administration of your UPMC Health Plan benefits program.

• Student Verification Form
  
• Out-of-Network Care Claim Form
  
• UPMC Health Plan Pharmacy Program Direct Reimbursement Claim Form
  
• Coordination of Benefits Verification
  
• HRA Claim Form
  
• Transition of Care Brochure
  
• Provider Nomination Form