For information on submitting claims online, please see
Hot Topic - Learn How to File Online Claims. The Employer Code for Boulder Valley School District is PBSBVSD.
Complete the form in its entirety (including participant name & signature, employer name, address) & staple Receipt(s) to claim form (when possible). Remit signed and completed claim form by fax or mail to:
PLANNED BENEFIT SYSTEMS, INC.
FAX# 303-221-2785
6377 S. Revere Pkwy-Suite 350
Centennial, CO 80111
Submit your provider receipt or explanation of benefits (EOB) from insurance company with all of the following information:
- Name of Service Provider
- Address of Service Provider
- Date of Service(s)
- Cost of Service
- Description of Service
Orthodontic and cosmetic work: See information on form. Daycare Claims must also include tax identification number or social security number.
If you are experiencing difficulties downloading the enrollment form, you can get a hard copy sent to you by e-mailing the Human Resources Office or call HRD at (303) 447-5031.