[et_pb_section fb_built=”1″ _builder_version=”4.25.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_row _builder_version=”4.25.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.25.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.25.2″ _module_preset=”default” global_colors_info=”{}”]<\/p>\n
[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=”1_3,1_3,1_3″ _builder_version=”4.25.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”1_3″ _builder_version=”4.25.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_text admin_label=”medical forms” _builder_version=”4.25.2″ _module_preset=”default” global_colors_info=”{}”]<\/p>\n
Spousal Coordination of Benefits Form<\/a> [\/et_pb_text][et_pb_text admin_label=”vision” _builder_version=”4.25.2″ _module_preset=”default” global_colors_info=”{}”]<\/p>\n Benefit Summary<\/a> [\/et_pb_text][et_pb_text admin_label=”LTD” _builder_version=”4.25.2″ _module_preset=”default” global_colors_info=”{}”]<\/p>\n The Hartford LTD Claim Form<\/a> [\/et_pb_text][\/et_pb_column][et_pb_column type=”1_3″ _builder_version=”4.25.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_text admin_label=”dental forms” _builder_version=”4.25.2″ _module_preset=”default” global_colors_info=”{}”]<\/p>\n Cigna Dental Benefit Summary Plan A<\/a> [\/et_pb_text][et_pb_text admin_label=”Life AD&D” _builder_version=”4.25.2″ _module_preset=”default” global_colors_info=”{}”]<\/p>\n Notice of Conversion<\/a> [\/et_pb_text][et_pb_text admin_label=”FSA” _builder_version=”4.25.2″ _module_preset=”default” hover_enabled=”0″ global_colors_info=”{}” sticky_enabled=”0″]<\/p>\n [\/et_pb_text][\/et_pb_column][et_pb_column type=”1_3″ _builder_version=”4.25.2″ _module_preset=”default” global_colors_info=”{}”][et_pb_text admin_label=”contact” _builder_version=”4.25.2″ _module_preset=”default” custom_padding=”||20px|17px|false|false” border_width_left=”1px” border_color_left=”#0C71C3″ global_module=”495″ saved_tabs=”all” locked=”off” global_colors_info=”{}”]<\/p>\n <\/b>For questions or more information on anything not listed, please contact the Brandywine Benefits Office:<\/strong><\/p>\n
CVS Reimbursement Form<\/a>
Dependent Coordination of Benefits – Aetna<\/a>
Dependent Coordination of Benefits – Highmark BCBS<\/a><\/p>\nVision<\/h3>\n
Informational Flier<\/a>
Your Hearing Member Flier<\/a>
VBA Member Portal Sheet<\/a>
VBA Out-of-Network Reimbursement Form<\/a><\/p>\nLong-Term Disability<\/h3>\n
Cigna LTD Claim Process<\/a>
Cigna LTD Claim Form<\/a>
LTD Insurance Certificate for Admins<\/a>
LTD Insurance Certificate for Non Admins<\/a><\/p>\nDental<\/h3>\n
Cigna Dental Benefit Summary Plan B<\/a>
Cigna<\/a>
myCigna.com<\/a><\/p>\nLife & AD&D Insurance<\/h3>\n
Conversion Application<\/a>
Portability Form<\/a>
Life Claim Form<\/a>
Certificate of Insurance<\/a><\/p>\nASI Flexible Spending Accounts<\/h3>\n
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Questions?<\/h3>\n