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Forms

Please find forms below:

• InterCounty Health Plans
  • Applications
    • Employer Master Application
    • InterCounty Employee Application
  • Misc Forms
    • Employee Change Form
    • ICHP FutureScripts Formulary
    • PA MiniCobra Info
    • Prescription MailOrder Form
    • Prescription Reimbursement Form
    • Student Confirmation Form
• Delta Dental Trust 2-4 Employees
  • Applications
    • Delta Dental Trust 2010 Employee Enrollment Form
    • Delta Dental Trust 2010 Group Application
    • Delta Dental Trust 2010 Submission Checklist
  • Brochures
    • Delta Dental Trust 2010 Brochure
    • Delta Dental Trust 2010 Rates
  • Misc Forms
    • Change / Termination Form
    • Delta Dental Claim Form
• Delta Dental SBA 5+ Employees
  • Applications
    • BA Agreement (HIPPA)- DC
    • BA Agreement (HIPPA)- DE
    • BA Agreement (HIPPA)- MD
    • BA Agreement (HIPPA)- NY
    • BA Agreement (HIPPA)- PA
    • BA Agreement (HIPPA)- WV
    • Employee Enrollment Form
    • Employee Enrollment Form- NY state
    • Group Application 2010
    • Group Application 2010- MD State
    • SBA Submission Checklist 2010
  • Brochures
    • Delta Care USA DHMO 2010
    • Delta Care USA DHMO Voluntary 2010
    • Delta Dental PPO 2010
    • Delta Dental PPO Plus Premier 2010
    • Delta Dental PPO Plus Premier Voluntary 2010
    • Delta Dental PPO Voluntary 2010
    • Delta Dental Program Highlights
    • Determining the Rates
  • Misc Forms
    • Notice of Privacy Policy 2010
    • SBA Change Form 2010
    • SBA Change Form NY State 2010
    • SBA Quick Guide 2010
• VSP - Vision Service Plan
  • Applications
    • Employee enrollment form
    • Group Application
    • VSP submission checklist
  • Brochures
    • VSP Brochure
  • Misc Forms
    • National-Regional Chains (Q&A)
    • PA VSP provider directory
• GettHealth® Misc. Forms
  • Misc Forms
    • Internet Acceptable Use Policy
    • PA Mini-COBRA Admin Overview
    • Student Confirmation Form
  • Questionnaires
    • Accident Injury - Work Related Medical Condition
    • Other Insurance
  • HIPAA
    • HIPAA ASO Authorization
    • ICHP HIPAA Authorization Form
• Section 125 - Cafeteria Plans (FSA/HRA/MERP/POP)
  • Applications
    • Section 125 Employee Change Form
    • Section 125 Employee Enrollment Form
  • Misc Forms
    • Dependent Care FSA Claim Form
    • Section 125 Claim Form