Forms and Applications

My Advance Care Plan (Form)

My Advance Care Planning Guide

Agent of Record - Change Request

Disabled Dependent Certification Form

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

Formulario para la autorización de un representante designado

Authorization to Release/Obtain PHI

Revocation of Authorization Form

Personal Health Information (PHI) Restriction Form

Confidentiality Agreement and Portal User Profile Form

Coordination of Benefits - Employers

Broker/Agent Electronic Payment Authorization Agreement

Application for Individual Health Coverage 2024

Optima Equity Health Savings Account (HSA) Enrollment Form

Small Group Employee BusinessEDGE Enrollment Application

Group Auto Debit Withdrawal BusinessEDGE

Small Group 10-150 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.pdf

Enrollment Application 51-150 2023

Enrollment Application Employee Health Questionnaire 2023

2023 Employer Group Application

Enrollment Application Small/Mid VA Group Medical History Form

HSA Enrollment Form

Enrollment Application Small/Mid Group Health Questionnaire

Enrollment Spreadsheet

1099 Eligibility and Attestation Form

Enrollment Application LG Combined 2023

Self Funded Member Enrollment Application

Enrollment Spreadsheet

HIPAA Agreement

Members Appeals Packet

Members Complaints Packet (Family Care)

Members Complaints Packet (Family Care)

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

Sentara Home Infusion Pharmacy Request Form for Injectables

Specialty Pharmacy FAQs (Proprium Pharmacy)

Instructions for Pharmacy Reimbursement

Prescription Drug Claim Form

Student Verification Form

Transitioning Care to Sentara Health Plans

COBRA 35% Letter

Optima Health ARRA Form

Virginia Small Employer COBRA