Forms: Evolve^SM and RealValue^SM Individual Plans and Innova^SM, Engage^SM, BluePoint, Employee Choice & HSA Healthplan 3.0^SM Group Plans and Regence Bridge Medigap Plans.

Individual

• Application (PDF) Eff. January 1, 2012 (Cover sheet, application and Authorization to Release Protected Health Information)
• EFT/Surepay Form (PDF)
• Domestic Partner Affidavit (PDF)
• Affidavit of Incapacitated Dependent (PDF)
• Authorization to Continue Coverage (PDF)
• Plan Change Request (PDF)
• Supplemental Health Questionnaires

For more information on Individual Products, see the Agent Toolbox

Medigap Plans

• Regence Bridge Medigap Plans - Coverage Effective 6/1/2010
  • Application (PDF)
  • Notice of Replacement Form (PDF)

  For more information, check the Medigap plans page.

MedAdvantage Plans

• Regence MedAdvantage (PPO)
• MA Scope of Sales Appointment Form - for agents (PDF)
• Enrollment Form 2012 (Fillable PDF)

For more information, check the MedAdvantage plans page.

Groups
For more information on Regence plans click here.

Small Groups (2-50)

• Member Enrollment - both forms must be completed and submitted together For groups effective 10/1/10 and after
  • Utah Small Employer Health Insurance Application (rev. 10/1/10)
    • English (Fillable PDF)
    • Spanish (Fillable PDF)
      
  • Small Employer Application Cover Sheet (Fillable PDF) Eff. 1/1/12 and beyond – Must accompany the form above for new hires in existing Regence groups and current members selecting continuation coverage.
• Group Master Application (rev. 1/1/12) (Fillable PDF)
• Renewal and Maintenance Change Request (1/1/12)
• Small Group Proposal Checklist
• Employee Choice Request Form

Medium Groups (51-99)

• Application for Enrollment/Change (Fillable PDF) Eff. 1/1/12 and beyond
• Waiver Form (Groups 51+) (Fillable PDF)
• Group Master Application (rev. 1/1/12) (Fillable PDF)
• Renewal and Maintenance Change Request (1/1/12)
• Risk Evaluation Form
• Spreadsheet Enrollment Procedure and Template (Groups 51-99 and 100+)
• Employer Center & Online Enrollment
  • Online Enrollment Set Up Checklist
• Short Form Health Questionnaire and Medical History Statement
  • English (Fillable PDF)
  • Spanish (Fillable PDF)
• Midsize Group Proposal Checklist

Large Groups (100+)

• Application for Enrollment/Change (Fillable PDF) Eff. 1/1/12 and beyond
• Application for Enrollment/Change (Groups 100+ ) (Fillable PDF) Eff. 1/1/12 and beyond
• Application for Enrollment/Change (Self Funded Group) (Fillable PDF) Eff. 1/1/12 and beyond
• Waiver Form (Groups 51+) (Fillable PDF)
• Group Master Applications
  • Group Size 100+ (rev. 1/1/12) (Fillable PDF)
  • Administrative Services Contract (rev. 1/1/12) (Fillable PDF)
• Renewal and Maintenance Change Request (1/1/12)
• Risk Evaluation Form
• Spreadsheet Enrollment Procedure and Template (Groups 51-99 and 100+)
• Employer Center & Online Enrollment
  • Online Enrollment Set Up Checklist

COBRA/Utah mini-COBRA/NetCare Continuation Coverage

Notices

• COBRA Administration Kit
• Model General Notice of COBRA Continuation Coverage Rights
• COBRA Model Continuation Coverage Election Notice and Form
• COBRA Notice of Termination
• COBRA Notice of Unavailability
• NetCare Employer Notification Procedure
• Utah mini-COBRA & NetCare Continuation Notice and Form

Applications

• COBRA, Utah mini-COBRA/NetCare Continuation or USERRA Application - Groups 51+ (Fillable PDF)
• Small Employer Application Cover Sheet (Fillable PDF) - For current members in groups size 2-50 selecting continuation coverage.

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

Conversion

• NetCare Conversion
  • Rates
    • 4th Qtr. 2011
    • 1st Qtr. 2012
  • Outline of Coverage
  • Enrollment Form
  • Surepay Authorization

Miscellaneous Member Forms

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

MISCELLANEOUS EMPLOYER FORMS

• Cancellation Request Form (Fillable PDF)
• Group Surepay Authorization (Fillable PDF)
• Michelle's Law - Employer Notice of Michelle's Law Qualification of Covered Dependent Child
• Agent Letter of Record (MS Word)

NOTICES

• Notice of Privacy Practices
• Women's Health and Cancer Rights Act Notice (WHCRA)
• USIIS Opt-Out Notice

MISCELLANEOUS AGENT FORMS

• Agent EFT Authorization