FORMS

NHADA Forms

NHADA Employee Application and Adjustment Form
This form is used by groups offering Dental, Life, Short-term Disability, and/or Vision Insurance.

The Notice of Termination of Coverage form is your official notification of a potential COBRA qualifying event; therefore, it is important that you submit this form as soon as possible. We suggest submittal within 48 hours of the event. The Notice of Termination of Coverage form must be received by NHADA prior to the effective date. Coverage will end on the last day of the month in which the Notice of Termination form was received.

Note: This form should not be used for voluntary cancellation of coverage, if an employee remains employed. Harvard Pilgrim enrollment forms can be used for this purpose; for other products, use the NHADA Employee Application and Adjustment form.

Harvard Pilgrim Health Care Forms

Harvard Pilgrim HMO Enrollment Form

Harvard Pilgrim PPO Enrollment Form

Harvard Pilgrim Health Coverage Waiver Form

Prescription Drug Mail Order Form

Fitness Reimbursement Claim Form

To claim reimbursement for an approved health club or fitness facility membership that you have paid for out-of-pocket.

Medical Reimbursement Claim Form

To claim reimbursement for medical and hospital services covered under your plan that you have paid for out-of-pocket.

Prescription Drug Reimbursement Claim Form

For HMO, POS and PPO Plans, to claim reimbursement for prescription medications covered under your plan that you have paid for out-of-pocket.

Pediatric Dental Claim Form

To claim reimbursement for covered dental care received outside the dental network.

Pediatric Vision Claim Form

To claim reimbursement for prescription eyeglasses and frames or prescription contact lenses covered under your plan that you have paid for out-of-pocket.

Behavioral Health Claim Form

To claim reimbursement for covered Behavioral Health services received out-of-network.

International Claim Form

To claim reimbursement for medical and hospital services received outside the U.S. that are covered under your plan.

Authorization to Release Information Form

To authorize Harvard Pilgrim to release/disclose certain health information according to the terms you specify.

Confidential Exchange of Information Form

To allow behavioral health practitioners involved in your care to release health information to other health providers according to the terms you specify.

Designation of Representative Form

To authorize an individual to discuss and make decisions related to your health care and coverage.

Disabled Adult Dependent Verification Form

To verify your dependent's eligibility as a disabled adult; includes Authorization to Obtain Protected Health Information.

Parental Rights Statement Form

To allow Harvard Pilgrim representatives to,speak to a parent about the health coverage and care of their dependent (under age 18) when the parent is not listed on that minor's policy. Must be notarized.

VSP Vision Care Forms

VSP Out-of-Network Claim Form

Life Insurance Forms

Life Beneficiary Claim Form

This form is used when an employee's beneficiary(ies) seek entitlement following the employee's death or dismemberment.

Complete form must be signed and mailed to: NHAD Services, Inc. - Insurance Division

NH Insurability Information Request (formerly the Anthem Life Evidence of Insurability Form)

This form must be completed and submitted with the employee's application when electing Life or Short-term Disability insurances if election of coverage was previously refused. For groups electing Short-term Disability, with fewer than six enrollees, Evidence of Insurability is always required. For groups electing Short-term Disability, with six or more enrollees, Evidence of Insurability is only required for the portion of the weekly benefit amount in excess of $500. Forms should be returned to:

NHAD Services, Inc. - Insurance Division

Short-Term Disability Forms

Short-term Disability Claim Form
This form is used when an employee, enrolled with Short-term Disability, is out of work for a qualified illness or injury. Please note that Part B must be completed by the attending physician. Return completed form to NHAD Services, Inc.- Insurance Division.

Short-term Disability Notice of Return to Work

This form is to be used when an employee returns to work following a short-term disability claim.

This form should be completed and returned to: NHAD Services, Inc. - Insurance Division

 


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