RESOURCE CENTER

Client Service Forms
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12.16.2011
Attestation form - Massachusetts’ Minimum Creditable Coverage (MCC)
Form to be completed by employer if they have MA residing employees who are enrolled on their group health plan. It should be returned to the appropriate group health insurer before 12/30.
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10.11.2011
Influenza Vaccine Reimbursement form
Form to be completed by members who receive an influenza vaccine out side of a doctor's office. Members are eligible for up to $25 reimbursement.
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06.29.2011
Amerihealth PA Enrollment form
Employee enrollment form to be used by someone who wishes to enroll into a Keystone group plan, yet resides in a non-contiguous county. Please consult with your Account Manager to discuss NCC rules and regulations.
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06.28.2011
Health, Allergy & Medication Questionnaire (HMQ)
Questionnaire to help Futurescript portect you against potentially harmful drug interactions and side effects.
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06.28.2011
FutureScripts mail-order form
Form to be completed by member and provider for mail-order prescription
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05.03.2011
Plan Sponsor Certification form
IBC branded form that will be sent to employers who have not made a benefit change. Employer must complete and return to IBC in order for IBC to know if they do or do not have a GF'd plan. This will affect information then mailed to members.
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03.16.2011
IBXpress letter
Letter required to grant broker access to IBXpress. Please place letter on group's letterhead, have owner/officer sign; send completed letter to your account manager.
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IBC Keystone Transmittal Form
IBC Keystone Transmittal Form
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03.16.2011
IBC Universal Enrollment Form
Employee enrollment form
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03.16.2011
IBC Universal Enrollment Form (Spanish)
Employee enrollment form in Spanish
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