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

• Application for Enrollment/Change
  • English
  • Spanish
• Group Health Questionnaire
  • English
  • Spanish
• Group Master Application
• Effective dates 8/1/08 to 12/1/08 (fillable PDF)
• Effective dates 1/1/09 and beyond (fillable PDF)
• Dual Option Matrices
  • 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)
• Waiver Form
  • English
  • Spanish
• Activate New Group Proposal Request (Groups 2-99)
• Innova & Engage New Group Proposal Request (Groups 2-99)
• Small Group Proposal Checklist
• Authorization to Disclose Health Information
• Authorization to Disclose Health Information (Spanish)/ Autorización para Divulgar Información Protegida de Salud

Medium Groups (51-99)

• Spreadsheet Enrollment Procedure and Template (Groups 51-99 and 100+) New!
• Application for Enrollment/Change
  • English
  • Spanish
• Short Form Health Questionnaire and Medical History Statement
  • English
  • Spanish
• Group Master Application
• Effective dates 8/1/08 to 12/1/08 (fillable PDF)
• Effective dates 1/1/09 and beyond (fillable PDF)
• Dual Option Guidelines
• Waiver Form
  • English
  • Spanish
• Activate New Group Proposal Request (Groups 2-99)
• Innova & Engage New Group Proposal Request (Groups 2-99)
• Midsize Group Proposal Checklist
• 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.
• Authorization to Disclose Health Information
• Authorization to Disclose Health Information (Spanish)/ Autorización para Divulgar Información Protegida de Salud

Large Groups (100+)

• Spreadsheet Enrollment Procedure and Template (Groups 51-99 and 100+) New!
• Application for Enrollment/Change
  • English
  • Spanish
• Short Form Health Questionnaire and Medical History Statement
  • English
  • Spanish
• Group Master Application
• Effective dates 8/1/08 to 12/1/08 (fillable PDF)
• Effective dates 1/1/09 and beyond (fillable PDF)
• Dual Option Guidelines
• Waiver Form
  • English
  • Spanish
• Activate New Group Proposal Request (Groups 100+)
• Innova & Engage New Group Proposal Request (Groups 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.
• Authorization to Disclose Health Information
• Authorization to Disclose Health Information (Spanish)/ Autorización para Divulgar Información Protegida de Salud

MISCELLANEOUS MEMBER FORMS

• Affidavit of Qualifying Incapacitated Dependent Eligibility
• Affidavit of Qualifying Domestic Partnership

MISCELLANEOUS EMPLOYER FORMS

• Surepay Authorization