Forms and Applications

My Advance Care Plan (Form)

My Advance Care Planning Guide

Agent of Record - Change Request

Authorization for Use or Disclosure of Medical Information (Designated Representative)

Authorization to Release/Obtain PHI

Revocation of Authorization Form

Personal Health Information (PHI) Restriction Form

Medicaid Primary Care Provider (PCP) Change Request

Formulario de solicitud de cambio de proveedor de atención primaria (PCP)

Disabled Dependent Certification Form

Formulario de Certificación de Dependiente Discapacitado

Confidentiality Agreement and Portal User Profile Form

Broker/Agent Electronic Payment Authorization Agreement

Application for Individual Health Coverage 2024

Sentara Equity/HSA Health Savings Account Enrollment Form

Small Group Employee BusinessEDGE Enrollment Application

Group Auto Debit Withdrawal BusinessEDGE

Group BusinessEDGE Enrollment Application

Small Group 20-50 BusinessEDGE Medical Risk Form

Small Group Enrollment Application 1-50 Member 2024

Small Group Enrollment Application 1-50 Member 2023

Enrollment Application 51-150 2024

Enrollment Application 51-150 2023

Enrollment Application Employee Health Questionnaire 2024

Enrollment Application Employee Health Questionnaire 2023

2024 Employer Group Application

2023 Employer Group Application

Enrollment Application Small/Mid VA Group Medical History Form

Enrollment Application Small/Mid Group Health Questionnaire

Enrollment Spreadsheet

1099 Eligibility and Attestation Form

2024 Employer Group Application

Enrollment Application LG Combined 2024

Enrollment Application LG Combined 2023

Enrollment Spreadsheet

HIPAA Agreement

Commercial Member Complaints Packet

Commercial Member Appeals Packet

Out-of-Area Dependent Child Form — for members enrolled in the Out-of-Area Dependent Program

Out-of-Area Dependent Child Form — for members whose employer has purchased the Out-of-Area dependent rider

Mail Order Frequently Asked Questions

Mirena Eligibility Form

Mirena Order Form

Specialty Pharmacy FAQs (Proprium Pharmacy)

Prescription Drug Claim Form

Transitioning Care to Sentara Health Plans

Virginia Small Employer COBRA