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Enrollment Type Forms:

Delta Dental Enrollment and Change Form
Delta Dental Enrollment and Change Form (Delaware County Only)
Employee Enrollment and Change Form
Employee Enrollment and Change Form (Delaware County Only)

General H&W Fund Forms/Documents:

Appeals Procedure 
Credible Coverage Letter
Delta Dental Non-Participating Claim Form 
Notice of Grandfathered Status
Negotiation Status Form (for Business Agent Use)
New Local Unit Application (for Business Agent Use)

Summary of Benefits & Coverage (SBC):

SBC-Bucks County 2022-23
SBC-Dauphin County 2022-23
SBC-Glossary of Terms

Express Scripts Forms:

Express Scripts Reimbursement Form 
Express Scripts Prescription Order Form 
Express Scripts Fax Order Form (Doctors Use Only)
Step Therapy Brochure

Bucks County Files:

Beneficiary Form (Bucks County Only)
Bucks County Hearing Aid Reimbursment Benefit 
Bucks County Hearing Aid Claim Form 
Bucks County Retiree.Letter.011811
Bucks County Retiree Health Reimbursement Arrangement Summary.Revised.December.2014
Bucks County Retiree HRA Claim Form
Bucks County Retiree-Verification Form
Bucks County Life Insurance Booklet
Bucks County Accident Insurance Booklet

Click here to download Adobe Reader for use with the .pdf files.
2589 Interstate Drive
Harrisburg, PA  17110-9602
Phone: 717-526-4856
Fax: 717-651-9529
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