Group Forms
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