The forms below are provided to assist you in completing claim-related needs.

If you have any questions regarding these forms, please call our Benefits Administration Department at 1-800-707-7726 and select Option 2.


These forms should only be used if Crescent Health Solutions is your Benefits Administrator; for any other claims payer, please refer to the contact information listed on your health plan ID card.

Dental Claim Form   - PDF

Medical Claim Form - PDF

Medical Claim Form - PDF-fillable


If your provider is Out-of-Network, you may submit the form below and Crescent Health Solutions will work with the provider if they are interested in joining the network.

Employee Request for Physician Participation with Crescent Network - PDF