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Applications

BusinessEDGE®

  • BusinessEDGE® Employee Enrollment Application (Height and Weight must be included for both underwriting and applying for coverage)
  • BusinessEDGE® Solicitud de inscripción del empleado, rechazo y coordinación de beneficios (Español)

Enrollment Applications Small Group 1-50

Only use these files for 1-50 plans (new hires, renewals)

  • 2022 Small Group 1-50 Member Enrollment Application
  • 2021 Small Group 1-50 Member Enrollment Application
  • 2021 Solicitud de inscripción y exención para grupos pequeños 1-50 Coordinación de beneficios (Español)

Enrollment Applications Mid Market 51-150 Eligible

  • 2022 Mid Market 51-150 Member Enrollment Application
  • 2021 Mid Market 51-150 Member Enrollment Application
  • 2021 Solicitud de inscripción y exención [Mid-market] Coordinación de beneficios (Español)

Employer Group Enrollment Applications (Small Group and Mid Market)

  • 2022 Employer Group Application
  • 2021 Employer Group Application
  • Virginia Group Health Insurance Medical History Form
  • Optima Equity Health Savings Account (HSA) Enrollment Form
  • Employer Group Health Questionnaire
  • Open Enrollment Spreadsheet
  • 1099 Eligibility and Attestation Form

Enrollment Applications (Large Group)

  • 2022 Combined Large Group Member Enrollment Application
  • 2021 Combined Large Group Member Enrollment Application
  • Self Funded Member Enrollment Application
  • Open Enrollment Spreadsheet

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© Optima Health 2022, 4417 Corporation Lane, Virginia Beach, VA 23462-3162

Optima Health is the trade name of Optima Health Plan, Optima Health Insurance Company, and Sentara Health Plans, Inc. Optima Health Maintenance Organization (HMO) products, and Point-of-Service (POS) products, are issued and underwritten by Optima Health Plan. Optima Preferred Provider Organization (PPO) products are issued and underwritten by Optima Health Insurance Company. Sentara Health Plans, Inc. provides administrative services to group and individual health plans but does not underwrite benefits. All Optima Health plans have benefit exclusions and limitations and terms under which the policy may be continued in force or discontinued. Optima Health Medicare, Medicaid, and FAMIS programs are administered under agreements with Optima Health and the Centers for Medicare and Medicaid Services (CMS) and the Virginia Department of Medical Assistance Services (DMAS).