• PPO Plans
• Compare Plans
• NC Health Choice
• Other Programs
• Indemnity Plan Archive

• My Member Services
• PPO Tools
• PPO FAQ
• PPO Enrollment
• Medical Policies
• Prior Authorization

• Benefits Booklet
• Appeals
• Prevention
• Mental Health
• PPO Forms
• Find a Doctor/Hospital

PPO forms are listed below. Click on the form you need, and follow the directions to submit the form to the State Health Plan.

Enrollment Form PPO (PDF, 81 KB)

Enrollment Form (PDF, 172 KB)
For National Guard, Fire Department, Rescue Squad and Emergency Medical Services Members

Change Form (PDF, 90 KB)

Worldwide International Claim Form (PDF, 32 KB)

Authorize a Representative (PDF, 66 KB)

Appeal a Decision (PDF, 57 KB)

Subrogation (Overpayment Form) (PDF, 143 KB)

Prior Coverage (PDF, 34 KB)