Forms: Activate^SM, Innova^SM, Engage^SM, & HSA Healthplan 2.0^SM

See other forms for the Individual, Medicare, Regence HSA Healthplan and BlueChoices^SM

Note: These forms are the most common ones that you'll need. Not all online forms are ready yet for these new products, but we'll add them here as they become available.

Small Groups (2-50)

• Member Enrollment - both forms must be completed and submitted together
  • Utah Small Employer Health Insurance Application (rev. 07/15/09) New!
  • Authorization for Use and Disclosure of Personal Protected Health Information New!
  • Small Employer Application Cover Sheet — Must accompany the two forms above for new hires in existing Regence groups and current members selecting continuation coverage.
• Group Master Application
• Dual Option Matrices (7/1/2009 and beyond)
  • HSA Healthplan 2.0/Innova/Engage Matrix (for groups 10-50)
  • Activate/Innova/Engage Matrix (for groups 25-50)
  • Innova/Engage Matrix (for groups 15-50)
• Activate New Group Proposal Request (Groups 2-99)
• Innova & Engage New Group Proposal Request (Groups 2-99)
• Small Group Proposal Checklist

Medium Groups (51-99)

• Application for Enrollment/Change
  • English
  • Spanish
• Waiver Form
  • English
  • Spanish
• Group Master Application
• Risk Evaluation Form
• Spreadsheet Enrollment Procedure and Template (Groups 51-99 and 100+)
• Employer Center & Online Enrollment
  • Online Enrollment Set Up Checklist
  • Employer Center Setup Form
    To add access to Employer Center outside of initial enrollment or at a group’s renewal anniversary.
• Short Form Health Questionnaire and Medical History Statement
  • English
  • Spanish
• Dual Option Guidelines (1/1/2009 and beyond)
• Activate New Group Proposal Request (Groups 2-99)
• Innova & Engage New Group Proposal Request (Groups 2-99)
• Midsize Group Proposal Checklist

Large Groups (100+)

• Application for Enrollment/Change
  • English
  • Spanish
• Waiver Form
  • English
  • Spanish
• Group Master Applications
  • Innova, Engage, Activate and HSA 2.0
  • Administrative Services Contract - Integrated Health Solutions
• Short Form Health Questionnaire and Medical History Statement
  • English
  • Spanish
• Risk Evaluation Form
• Dual Option Guidelines
• Spreadsheet Enrollment Procedure and Template (Groups 51-99 and 100+)
• Employer Center & Online Enrollment
  • Online Enrollment Set Up Checklist
  • Employer Center Setup Form
    To add access to Employer Center outside of initial enrollment or at a group’s renewal anniversary.
• Innova & Engage New Group Proposal Request (Groups 100+)
• Activate New Group Proposal Request (Groups 100+)

COBRA and Special Enrollment Forms

• COBRA Booklet
• COBRA, UTAH mini-COBRA/STATE CONTINUATION or USERRA Application

For fillable COBRA notices visit www.dol.gov/COBRA

CONVERSION

• NetCare Conversion - for enrollment on or after January 1, 2010
  • Outline of Coverage
  • Benefit Summary
  • Rates
  • Enrollment Form
  • Surepay Authorization
• Conversion Plan - for enrollment through December 31, 2009

MISCELLANEOUS MEMBER FORMS

• Authorization to Disclose Protected Health Information
• Authorization to Disclose Protected Health Information (Spanish)/ Autorización para Divulgar Información Protegida de Salud
• Affidavit of Qualifying Incapacitated Dependent Eligibility
• Affidavit of Qualifying Domestic Partnership
• Member Reimbursement Claim Form
• Incident Report
• Michelle's Law - Dependent Child Certification

MISCELLANEOUS EMPLOYER FORMS

• Surepay Authorization
• Michelle's Law - Employer Notice of Michelle's Law Qualification of Covered Dependent Child

NOTICES

• Your Special Enrollment Period Rights
• Notice of Preexisting Condition Exclusion