Forms and Applications
Advanced Directives
My Advance Care Plan (Form)
PDF, 367 KB
PDF, 367 KB
My Advance Care Planning Guide
PDF, 2 MB
PDF, 2 MB
Agent of Record Form
Agent of Record - Change Request
PDF, 509 KB
PDF, 509 KB
Authorizations for Release of Medical Information
Authorization for Use or Disclosure of Medical Information (Designated Representative)
PDF, 115 KB
PDF, 115 KB
Authorization to Release/Obtain PHI
PDF, 71 KB
PDF, 71 KB
Revocation of Authorization Form
PDF, 82 KB
PDF, 82 KB
Personal Health Information (PHI) Restriction Form
PDF, 80 KB
PDF, 80 KB
Medicaid Primary Care Provider (PCP) Change Request
PDF, 630 KB
PDF, 630 KB
Formulario de solicitud de cambio de proveedor de atención primaria (PCP)
PDF, 95 KB
PDF, 95 KB
Disabled Dependent Certification Form
PDF, 562 KB
PDF, 562 KB
Formulario de Certificación de Dependiente Discapacitado
PDF, 536 KB
PDF, 536 KB
Broker Appointments
Broker Sign In
Electronic Commission Payments Reports
Enrollment Applications
BusinessEDGE
Small Group Employee BusinessEDGE Enrollment Application
PDF, 791 KB
PDF, 791 KB
Small Group Employee BusinessEDGE Enrollment Application (en Español)
PDF, 481 KB
PDF, 481 KB
Group Auto Debit Withdrawal BusinessEDGE
PDF, 81 KB
PDF, 81 KB
Group BusinessEDGE Enrollment Application
PDF, 318 KB
PDF, 318 KB
Small Group 20-50 BusinessEDGE Medical Risk Form
PDF, 1 MB
PDF, 1 MB
Enrollment Applications Small Group 1-50
Enrollment Applications Mid-Market 51-150 Eligible
Employer Group Enrollment Applications Small Group and Mid Market
2024 Small Group Employer Application
PDF, 311 KB
PDF, 311 KB
Enrollment Application Small/Mid VA Group Medical History Form
PDF, 271 KB
PDF, 271 KB
Enrollment Application Small/Mid Group Health Questionnaire
PDF, 290 KB
PDF, 290 KB
Enrollment Spreadsheet
XLSX, 353 KB
XLSX, 353 KB
1099 Eligibility and Attestation Form
PDF, 544 KB
PDF, 544 KB
Employer Group Enrollment Applications Large Group
Enrollment Applications Large Group
HIPAA Agreement for PHI
HIPAA Agreement
PDF, 26 KB
PDF, 26 KB
Member Appeals Forms
Member Complaint Packet
PDF, 167 KB
PDF, 167 KB
Commercial Member Appeals Packet
PDF, 100 KB
PDF, 100 KB
Self-Funded Appeal Packet
PDF, 309 KB
PDF, 309 KB
Out-of-Area Dependent Child Forms
Pharmacy Mail Order Forms
Mail Order Frequently Asked Questions
PDF, 431 KB
PDF, 431 KB
Mirena Eligibility Form
PDF, 71 KB
PDF, 71 KB
Mirena Order Form
PDF, 42 KB
PDF, 42 KB
Specialty Pharmacy FAQs (Proprium Pharmacy)
PDF, 152 KB
PDF, 152 KB
Pharmacy Reimbursement Form
Prescription Drug Claim Form
PDF, 112 KB
PDF, 112 KB
Transitional Care Forms
The American Recovery and Reinvestment Act of 2009 Forms
Virginia Small Employer COBRA
PDF, 70 KB
PDF, 70 KB