Forms

Advanced Directives

• My Advance Care Plan (Form)
• My Advance Care Planning Guide

Authorizations for Release of Medical Information

• Disabled Dependent Certification Form
• Designated Representative Authorization Form
• Formulario para la autorización de un representante designado
• Authorization for Use or Disclosure of Medical Information - THIS FORM MUST BE USED BY HEALTH EQUITY MEMBERS ONLY
• Authorization for Use or Disclosure of Medical Information (Designated Agent)
• Revocation of Authorization Form
• Personal Health Information (PHI) Restriction Form

Coordination of Benefits

• Coordination of Benefits form

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)
• BusinessEDGE® Group Auto Debit Withdrawal Form
• BusinessEDGE® Employer Application
• BusinessEDGE® Medical Risk Form/High Risk and High Cost Conditions List

Employer Sign In

• Confidentiality Agreement and Portal User Profile Form

Member Appeals Forms

• Member Appeals Packet
• Member Complaints Packet
• Member Complaints Packet (Family Care Members)

Out-of-Area Dependent Child Forms

• 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

Pharmacy Mail Order Forms

• Mail Order Form
• Mail Order Frequently Asked Questions
• Mirena Eligibility Form
• Mirena Order Form
• Sentara Home Infusion Pharmacy Request Form For Injectables
• Specialty Pharmacy FAQs (Briova)
• BriovaRx Request Form for Injectables
• Specialty Pharmacy FAQs (Proprium Pharmacy)

Pharmacy Reimbursement Form

• Direct Member Reimbursement Form
• Instructions for Pharmacy Reimbursement

Student Verification Forms

• Student Verification Form

Transitional Care Forms

• Transitional Care Request Form

The American Recovery and Reinvestment Act of 2009 Forms

• Virginia Small Employer COBRA
• COBRA 35% Letter
• Optima Health ARRA Form