Select the appropriate form below.
“The Families First Coronavirus Response Act requires private health plans (including insured, self-insured, and grandfathered, as defined in section 1251(e) of the Patient Protection and Affordable Care Act)) and government programs (including Medicare and Medicaid) to provide coverage for COVID-19 diagnostic testing and related services free of charge (without cost-sharing, such as deductibles, copayments, and coinsurance) to the public, through the end of the national COVID-19 emergency period.
Covered services and related cost waivers apply to diagnostic testing, healthcare provider services (in-person and telehealth), and facility costs (physician office, urgent care center, and emergency room) to the extent the costs are related to the evaluation and diagnosis of COVID-19. Prior authorization or other medical management requirements for such services do not apply through the end of the national COVID-19 emergency period. If the visit does not result in a COVID-19 test, or provides services unrelated to COVID-19 testing, cost-sharing and plan limitations may apply. The Families First Coronavirus Response Act does not require group health plans or insurers to cover treatment for complications related to COVID-19. If testing finds COVID-19 to be present, treatment of the complications will likely be subject to normal cost-sharing and network requirements.”
For Carrollton Bank Health Plan
- Carrollton Bank Accident Questionnaire
- Claim Form
- Carrollton Bank Coordination of Benefits
- Carrollton Bank HIPPA Authorization Form
For Clayco Group Health Plan
For FCB BANKS Group Health Plan
For Hermann Area Hospital District Group Health Plan
- Hermann Accident Questionnaire
- Claim Form
- Hermann Coordination of Benefits Form
- Hermann HIPPA Authorization Form
If you have any questions or concerns regarding these forms, please contact our Member Service team at 877-875-7700.