Forms

My Advance Care Plan (Form)

My Advance Care Planning Guide

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

Authorization for Use or Disclosure of Medical Information - THIS FORM MUST BE USED BY HEALTH EQUITY MEMBERS ONLY

Authorization to Release/Obtain PHI

Revocation of Authorization Form

Personal Health Information (PHI) Restriction Form

Disabled Dependent Certification 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

Confidentiality Agreement and Portal User Profile Form

Members Complaints Packet

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

Specialty Pharmacy FAQs (Proprium Pharmacy)

Commercial and Medicaid Member Reimbursement Form

Transitioning Care to Sentara Health Plans

Virginia Small Employer COBRA