Forms and Documents

Group Application / Enrollment Forms

• Small Group Application (Groups of 2-50)
• Small Group Enrollment/Change Form (Groups 2-50)
• Small Group Renewal Form (Groups 2-50)
• Small Group New Enrollment Checklist
• Large Group Application (Groups of 51+)
• Large Group Enrollment/Change Form (Groups of 51+)
• Large Group New Enrollment Checklist

Other Forms

• Appoint a Representative - authorize someone to act on your behalf
• Common Ownership Verification
• Continuation of Coverage Form
• Coordination of Benefits Questionnaire
• Healthy Lifestyle Rebate Form
• Participation Validation
• Agent Worksheet for Employer Eligibility

Pharmacy / Medical Orders & Authorizations

• Medical Reimbursement Form
• Mail Order Prescriptions
• Pharmacy Authorization/Exception Request Form for Members - must be completed and submitted by your physician
• Prescription Mail Order Form
• Prescription Drug Reimbursement Form

General Information

• Covered Preventive Services
• Fitness Membership (Active&Fit)
• Health Education Programs
• Agency for Health Care Administration
• Member Rights and Responsibilities
• Notice of Privacy Practices
• Provider Directory
• Member Guidebook - Except TPA plans
• Transparency in Coverage
• Urgent Care
• More About our Secure Web Site