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Group Enrollment / Change Forms

The information below is needed in order to process enrollment changes within group plans. Attached you will find the enrollment/change forms, fax number, and carrier producer phone number. If you are having difficulty accessing the forms please feel free to contact us at 814.372.4607.

Carrier

Producer Number

Fax Number

Enrollment Form

Aetna

888-282-3862

800-975-1768

Aetna EnrollmentChange Form.pdf

Always Care

888-729-5433

225 610-1428

Always Care Enrollment Application.doc

Blue Cross NEPA

877-292-0714

570-558-4695

BCNEPA Enrollment Application.pdf
BCNEPA Enrollment Change Form.pdf

Capital Blue Cross

800.348.8172

717-540-2350

CBC Enroll or Change Enrollment.pdf

Delta Dental

866-760-4080

717 766-8719

Delta Dental enrollment change form.pdf

Geisinger Health Plan

866-488-6653

570-808-5427

Geisinger change form.pdf

Guardian

800-627-4200

920-749-6058

Guardian enrollment form.pdf

Health America

866-613-4976

717-526-2920

HA Enrollment Change Form.pdf

Highmark Blue Cross Blue Shield

866-602-1248

866-718-0804

Highmark Enrollment Form.pdf
Highmark Member Change Form.pdf

Highmark Blue Shield

800-597-2450

717-302-3534

HBS Member change form.pdf
HBS Member Enrollment Application.pdf

Independence Blue Cross

610-240-7317

610-644-9277

IBX Employee Enrollment form.pdf

National Vision Administrators

973-574-2528

973-574-2416

NVA Enrollment Change Form.pdf

United Concordia

888-898-0353

800-329-9093

United Concordia Change Form.pdf

United Healthcare

888-842-4571

800 711-7630

UHC Enrollment Form.pdf

UPMC Health Plan

888-499-6922

412-454-7770

UPMC Change Form.pdf
UPMC Election Form.pdf

Vision Benefits of America

800-432-4955

717-761-8036

VBA Direct Enrollment Form.doc