USNow Change Form

This form is required in order to process any changes to a member's record.   This includes:

• Changes to address, name, phone
• Request a new ID card or Fulfillment
• Cancellations, Terminations and Additions

HIPAA Authorization Form

USNow HIPAA Authorization Form

PALIC Evidence of Insurability Form

Pan-American Life Insurance Company (PALIC) Evidence of Insurability Form

 DEATH CLAIM

PALIC Death Claim Form

Pan-American Life Insurance Company (PALIC) Death Claim Form for Members and Dependents

 HOSPITAL INDEMNITY CLAIM

PALIC Medical Claim Form

Pan-American Life Insurance Company (PALIC) 
Supplemental Hospital and Medical Indemnity Claim Form

DISABILITY, CANCER & CRITICAL ILLNESS CLAIM

PALIC Short Term Disability Claim Form

Pan-American Life Insurance Company (PALIC) Short-Term Disability Plus Claim Form

MSL DI Claim Form

Member Service Life Short-Term Disability Claim Form

PALIC Cancer & Preventive Claim Form

Pan-American Life Insurance Company (PALIC) Cancer and Preventive Claim Form

MEDICAL ACCIDENT CLAIM

GTL Accident Medical
Claim Form

Guarantee Trust Life Insurance Company (GTL) Accident Medical Claim Form

 DENTAL CLAIM

MWG Dental Claim Form

Morgan White Dental Claim Form

 PRESCRIPTION

PPA Client Application

Preferred Prescription Assistance - Client Application

Discount Prescription 
Mail Order Form

IPS Prescription Mail Order Form

RxEDO Mail Service Pharmacy Tips

RxEDO Mail Service Pharmacy Tips Sheet

RxEDO Prescription Mail Order Form

RxEDO Prescription Mail Order Form

RxEDO Prescription Fax Order Form

RxEDO Prescription Fax Order Form

RxEDO Prescription Reimbursement Form

RxEDO Prescription Drug Program Direct Reimbursement Form - FILLED AFTER 5/1/06