| EMPLOYER FORMS |
| Group Master Application |
Use this form to apply
for group coverage through Regence. Please call
us or contact your broker to get a copy of
this form. |
Employee
Enrollment & Change Form
English Version (PDF) Spanish Version (PDF) |
Use this form to add
new members, add or cancel dependents, change a
member's eligibility status, or update any other
employee information. The form must be signed by
the group administrator. |
| Eligibility Adjustments (PDF) |
Use this form to calculate premium due when new enrollment, status changes or member cancellations have been made. |
| Micro
Group (2-3 employees) Request For Proposal (Fillable PDF) |
Businesses with two
to three employees can submit this form to obtain
a quote for group medical coverage through Regence. |
| MANDATE CHANGES |
Brief description of mandate changes
DSHS Mandate Description |
Contract Riders
Brochure Inserts
|
| EMPLOYEE & MEMBER FORMS |
| Affidavit
of Qualifying Domestic Partnership (PDF) |
Employees and their
domestic partners applying for coverage should
complete this form and should send completed affidavits
with completed Employee Enrollment and Change forms. |
| Affidavit of Qualifying Incapacitated Dependent Eligibility (Fillable PDF) |
Use this form to certify that an eligible dependent child is incapacitated due to medical disability, developmental disability or mental disorder. |
Employee
Enrollment & Change Form
English Version (PDF) Spanish Version (PDF) |
Use this form to add
new members, add or cancel dependents, change a
member's eligibility status, or update any other
employee information. The form must be signed by
the group administrator. |
| Incident
Report (PDF) |
Members who need medical
care as a result of an injury or accident may be
asked to complete this form and submit it to Regence. |
| Member Reimbursement Form (PDF) |
Members can use this form to submit claims for covered services, or prescription plans that require you to pay out of pocket and submit for reimbursement. |
| Multiple
Coverage Inquiry (PDF) |
Employees who are covered
under a spouse's health plan as well as a Regence
plan should complete this form and mail it
to Regence. |
| Prior
Coverage Information (PDF) |
Employees or dependents
who are applying for coverage or who have recently
(within the last 12 months) come onto coverage
through Regence, and had other medical
coverage within six months before starting Regence coverage, should complete this form.
The information will be used to establish eligibility
for credits on benefit waiting periods. |
| Waiver
Form (PDF) |
Employees who decline
health care coverage through Regence
because of other coverage should complete this
form. |
| PRESCRIPTIONS |
|
| Postal
Prescription Services (PPS) (PDF) |
Members can use this form to
order new prescriptions from
PPS mail-order service.
For prescription refills and
other information, visit the PPS
Web site. |
| NOTICES |
|
Annual Notification
• Small
Groups (1-50)
• Large
Groups (51+)
• Large
Groups (51+ No Wait)
|
Annual notification regarding group
plan coverage. Information for group administrators
to share with all members and dependents. |
Creditable Coverage Notice Forms - Medicare Part D |
Creditable Coverage (Word Document)
Non-Creditable Coverage (Word Document) |
| DISCLOSURES |
|
| Pre-Sale Disclosure (PDF) |
Pre-sale disclosure statement – Health Care Patient Bill of Rights |
| Post-Sale Disclosure (PDF) |
Post-sale disclosure statement – Health Care Patient Bill of Rights |
| BROCHURE INSERTS |
|
| Medical and dental benefit brochure insert for Coordination of Benefits (COB) Administrative Rule change (PDF) |
For claim dates of service on or after September 1, 2009.
Preferred Plans, Selections Plans, HSA-Qualified Preferred Plans 80/80/60, Regence HSA Healthplan, Traditional Plans, and Traditional Dental Plans |
