Forms and Applications

Advanced Directives

Agent of Record Form

Associations Applications

Authorizations for Release of Medical Information

Broker Appointments

Broker Guides

Coordination of Benefits

Electronic Commission Payments/Reports

Enrollment Applications


Enrollment Applications Small Group 2-50

Only use these files for 2-50 plans (new hires, renewals)

Enrollment Applications 2017 Mid-Market 51-150 Eligible

Enrollment Applications 2018 Mid-Market 51-150 Eligible

Enrollment Applications 2016 Mid-Market 51-99

Only use these files for Mid Market 51-99 plans

Enrollment Applications 2016 Mid-Market 100-150

Use these files for plans effective dates of 10/1/16 – 12/1/16

Employer Group Enrollment Applications (Small Group and Mid Market)

Enrollment Applications (Large Group)

HIPAA Agreement for PHI

Member Appeals Forms

Member Verification Form

Out-of-Area Dependent Child Forms

Pharmacy Mail Order Forms

Pharmacy Reimbursement Form

Student Verification Forms

Transitional Care Forms

The American Recovery and Reinvestment Act of 2009 Forms