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, 234 KB
PDF, 234 KB
Authorizations for Release of Medical Information
Disabled Dependent Certification Form
PDF, 125 KB
PDF, 125 KB
Authorization for Use or Disclosure of Medical Information (Designated Representative)
PDF, 165 KB
PDF, 165 KB
Formulario para la autorización de un representante designado
PDF, 237 KB
PDF, 237 KB
Authorization to Release/Obtain PHI
PDF, 101 KB
PDF, 101 KB
Revocation of Authorization Form
PDF, 137 KB
PDF, 137 KB
Personal Health Information (PHI) Restriction Form
PDF, 79 KB
PDF, 79 KB
Broker Appointments
Broker Sign In
Coordination of Benefits
Electronic Commission Payments Reports
Enrollment Applications
BusinessEDGE
Enrollment Applications Small Group 1-50
Enrollment Applications Mid-Market 51-150 Eligible
Employer Group Enrollment Applications Small Group and Mid Market
2023 Employer Group Application
PDF, 294 KB
PDF, 294 KB
Enrollment Application Small/Mid VA Group Medical History Form
PDF, 271 KB
PDF, 271 KB
HSA Enrollment Form
PDF, 1 MB
PDF, 1 MB
Enrollment Application Small/Mid Group Health Questionnaire
PDF, 196 KB
PDF, 196 KB
Enrollment Spreadsheet
XLSX, 380 KB
XLSX, 380 KB
1099 Eligibility and Attestation Form
PDF, 79 KB
PDF, 79 KB
Enrollment Applications Large Group
Enrollment Application LG Combined 2023
PDF, 357 KB
PDF, 357 KB
Self Funded Member Enrollment Application
PDF, 1016 KB
PDF, 1016 KB
Enrollment Spreadsheet
XLSX, 380 KB
XLSX, 380 KB
HIPAA Agreement for PHI
HIPAA Agreement
PDF, 26 KB
PDF, 26 KB
Member Appeals Forms
Out-of-Area Dependent Child Forms
Pharmacy Mail Order Forms
Pharmacy Reimbursement Form
Student Verification Forms
Student Verification Form
PDF, 49 KB
PDF, 49 KB
Transitional Care Forms
The American Recovery and Reinvestment Act of 2009 Forms
COBRA 35% Letter
PDF, 345 KB
PDF, 345 KB
Optima Health ARRA Form
PDF, 43 KB
PDF, 43 KB
Virginia Small Employer COBRA
PDF, 70 KB
PDF, 70 KB