Forms
Advanced Directives
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
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 & High Cost Conditions List
Employer Sign In
Member Appeals Forms
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)