Gives
BackGroup 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
- Small Group Employer eligibility agent worksheet
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