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ALLIED PILOTS ASSOCIATION ENROLLMENT/CHANGE FORM Return completed form to WEB-TPA P. O. Box 1987 Grapevine TX 76099-1987 1-800-477-8957 Fax 469-417-1979 VOLUNTARY SUPPLEMENTAL MEDICAL CUSTODIAL CARE BENEFIT PLAN SMP Check appropriate box. I Enrollment/Re-enrollment Name Last First Middle Initial I Dependent Change Street Address Employee Number City Date of Birth MO/DAY/ YR / Date of Hire State Zip Code Date of Recall First Name Gender I Married I Single I American Airlines I Staff List any periods of furlough paid or unpaid leave of absence sick personal family leave military leave etc* List dependents to be covered Last Name Telephone Number Status Check one I Active Flight Status I Retired I TAG I LOA I Surviving Spouse I Furlough I Military I SLOA I MDSB Date of Furlough Social Security Number Spouse Dependent Child If you are adding a spouse due to marriage or a dependent due to birth you must attach supporting documents i*e* marriage certificate birth certificate or coverage will....

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If you have further questions, please call 844.380. 4554, email helpme@webtpa.com or fill out the Ask A Question form on your WebTPA Provider Portal at .webtpa.com.

WebTPA is the claims administrator and they handle matters such as eligibility, processing and paying claims on the City's behalf, determining plan coverage, etc. WebTPA is the number on your insurance card that you will call for benefit questions.

Note: Customer Service: (800) 241-7475. Blue Card:(800) 628-3988.

Payer Name: Freedom Life Insurance Company|Payer ID: 62324|Professional (CMS1500)/Institutional (UB04)[Hospitals]

The Payer ID or EDI is a unique ID assigned to each insurance company. It allows provider and payer systems to talk to one another to verify eligibility, benefits and submit claims. The payer ID is generally five (5) characters but it may be longer. It may also be alpha, numeric or a combination.

Request a Payer Payer IDPayer Name75261Community Health Plan /CHEC/ Web Tpa75261CHEC (Subsidiary of Sprint)75261Community Health Electronic Claims (CHEC)75261WebTPA

To ensure faster turnaround time and efficiency, BCBSTX recommends that your software have the capability to electronically retransmit individually rejected claims. Plan health care providers submitting claims via the Availity Health Information Network must use payer identification code 84980.

P.O. Box 1928. Grapevine, Texas 76099. GROUP HEALTH CLAIM FORM. FAX (469) 417-1960. PLEASE COMPLETE FORM COMPLETELY. A GROUP HEALTH CLAIM FORM MUST BE COMPLETED FOR EACH CLAIM SUBMITTED. ATTACH ALL BILLS/CORRESPONDENCE IF YOUR PHYSICIAN IS NOT FILING THE CLAIM FOR YOU.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232