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PEBTF-2 Form Revised 9-2011 Document icon
PEBTF-2 Enrollment/Change form.
PEBTF-12 Domestic Partner Verification Statement Document icon
Form to establish domestic partner relationship for health benefits.
Allergenic Extract Claim Form Document icon
Claim form for allergenic extract reimbursement.
Prescription Drug Mail Order Form Document icon
Form to set up mail-order prescription service.
CVS Caremark Prescription Drug Claim Form Document icon
Claim form for prescription drug claims (out-of-network providers).
National Vision Administrators Claim Form Document icon
Claim form for vision claims (out-of-network providers).
United Concordia Dental Plan Claim Form Document icon
Claim form to submit incurred dental expenses (out-of-network providers).
Hearing Aid Claim Form Document icon
Claim form for hearing aid services and/or supplies.
 
  • Human Resources Office
  • Sutton Hall, Room G8
    1011 South Drive
    Indiana, PA 15705
  • Phone: 724-357-2431
  • Fax: 724-357-2685
  • Office Hours
  • Monday through Friday
  • 8:00 a.m.–4:00 p.m.