Forms: Evolve Individual Plans and Innova, HSA Healthplan 2.0 and Employee Choice Group Plans and Regence Bridge Medigap Plans.

See other forms for Medicare, Preferred Plan FourFront, Regence HSA Healthplan, Preferred Plan, Selections and other health plans.

INDIVIDUAL

• Regence Evolve Comparison Brochure (PDF)
• Application (PDF)
• Health Questionnaire (PDF)
• Rate Sheet (PDF) Eff. 10/1/2011
• Rate Sheet (PDF) Eff. 04/1/2012
• EFT/Surepay Form  (PDF)
• Domestic Partner Affidavit (PDF)
• Affidavit of Incapacitated Dependent (PDF)
• Non-smoker Certification Form (PDF)
• Evolve Plan Change Form (PDF)
• Authorization to Continue Coverage (PDF)
• Agent of Record Change Form (PDF)

MEDIGAP

• Regence Bridge Application (PDF)
• Regence Bridge Outline of Coverage (PDF)
• Regence Bridge Notice of Replacement Form (PDF)

GROUP

• Micro Group Forms
  • Micro Group Request for Proposal (PDF)
  • Micro Group Employer Documentation (PDF)
• Cancellation Request Form
  
• Group Master Applications - Eff. 07/01/2012 and beyond
  • Groups 1-99 Employees
  • Groups 100+ Employee
• Group Master Applications - Eff. 01/01/2012 to 06/30/2012
  • Groups 1-99 Employees
  • Groups 100+ Employees
• Group Change Notification (PDF) NEW!
• Spreadsheet Enrollment Procedure and Template (Groups 2+)
• Dual Option Guidelines
• 2011 Dual Option Guidelines (Groups 51+) (PDF) - Eff. 7/1/10 through 12/31/11
• 2012 Dual Option Guidelines (Groups 51+) (PDF) - Eff. 01/01/12 and beyond
• Dual Option Matrices
• Eff. 7/1/10 through 12/31/11:
  • Innova/Engage/HSA 2.0 Dual Option Matrix (Groups 10-50) (PDF)
  • Innova/Engage Dual Option Matrix (Groups 25-50) (PDF)
  • Innova/Engage/Activate Dual Option Matrix (Groups 25-50) (PDF)
• Eff. 1/1/12 and beyond:
  • Innova/ HSA 2.0 Dual Option Matrix (Groups 10-50) (PDF)
  • Innova Dual Option Matrix (Groups 25-50) (PDF)
• Request for Proposal (PDF)
• Renewal and Maintenance Change Request
• Application for Enrollment/Change (PDF) Eff. 1/1/12 and beyond
• Application for Enrollment/Change (Groups 100+ Self Insured) Eff. 1/1/12 and beyond
• Delayed Enrollment Exception Request - Coming Soon
• Waiver Form
• Verification of Employment
• Affidavit of Qualifying Domestic Partnership
• Affidavit of Qualifying Incapacitated Dependent Eligibility
• Online Enrollment Set-up Checklist (PDF)
• Employer Center Setup Form
• Surepay Authorization Form
• Authorization for Use and Disclosure of Protected Health Information (PDF)

Spanish Language Forms / Formularios en Español

• Waiver Form / Formulario de renuncia
• Authorization to Disclose Health Information / Autorización para Divulgar Información Protegida de Salud
• Application for Enrollment/Change (Spanish) (PDF)