• Individual Products
• Medicare Plans
• Group
• Life & Disability
• Member Forms and Notices

Individual Products

• Apply for Coverage - All three documents below must be filled out and turned in together
  • Regence Individual Application Cover Sheet
  • Utah Individual Health Insurance Application (rev. 7/15/2009) New!
  • Authorization for Use and Disclosure of Protected Health Information
• Conversion Application
• Plan Change Form
• Individual and Family Plan Outline of Coverage
• Individual Plans Comparison
• SurePay Information and Authorization
• Individual Health Change Form E-27
• Individual Health Change Form E-27 (Spanish)
• Application for Crediting Prior Coverage
• Individual Health Questionnaires Scroll down and choose a form -------------------------------------------- ACNE / SKIN DISORDERS ALCOHOL / DRUG ADDICTION ARTHRITIS / BONE / MUSCLE BACK OR NECK CHEST PAIN COLITIS / IRRITABLE BOWEL SYNDROME CYST / POLYP / TUMOR / BREAST DIVERTICULITIS / DIVERTICULOSIS EYE OR EAR FEMALE DISORDERS GOUT HEADACHE OR MIGRAINE HEART MURMUR / MITRAL VALVE PROLAPSE / RHEUMATIC FEVER HERNIA / GERD KIDNEY / BLADDER / PROSTATE MENTAL / NERVOUS DISORDERS RESPIRATORY DISORDERS / ASTHMA / BRONCHITIS / SINUSES / ALLERGIES SHOULDER / KNEE / JOINT SEIZURE / EPILEPSY THYROID ULCER

Medicare Plans

• Application for Supplement
• BlueSelect Program Book
• BlueSelect Rates
• Medicare Supplement Program Book
• Medicare Supplement Rates
• SurePay Form for Medicare (PDF)
• Regence MedAdvantage (PPO)
  • Enrollment Forms
    • 2009
    • 2010
  • Short Enrollment Forms (for members upgrading their plan)
    All pages of this form must be given to inquiring or applying individuals.
    • 2009
    • 2010
• Regence Life and Health Medicare Script (PDP)
  • Enrollment Forms
    • 2009
    • 2010
  • Short Enrollment Forms (for members upgrading their plan)
    All pages of this form must be given to inquiring or applying individuals.
    • 2009
    • 2010

Group

New Large Groups (100+)
BLUE CHOICES ONLY

• Application for Enrollment/Waiver (Print and complete two copies of this PDF form. Sign one form and send it in, save the second for your records.)
• Application for Enrollment/Waiver (Spanish)
• Prior Coverage Information
• Group Application Form (Complete this PDF form and print two copies. Sign one form and send it in, save the second for your records.)
• Risk Evaluation Form
• Dental Application for Regence BlueCross BlueShield Dental or Regence ValueCare Dental
• Group Change Form
• Large Group Proposal Request
• Verification of Fee Arrangement (for agent)
• Conversion/Interplan Transfer Application

Member Forms and Notices: New Member enrollment for existing BlueChoices Groups

Group Size 2-50

• Member Enrollment - both forms must be completed and submitted together

  Member enrollment for current groups of 2-50. All forms must be completed and submitted together

  • Utah Small Employer Health Insurance Application (rev. 07/15/2009) New!
  • Authorization for Use and Disclosure of Protected Health Information New!
  • Small Employer Application Cover Sheet
• Group Dental Application

Group Size 51-99

• Application for Enrollment/Waiver (Print and complete two copies of this PDF form. Sign one form and send it in, save the second for your records.)
• Application for Enrollment/Waiver (Spanish)
• Short Form Health Questionnaire & Medical history (Contact Marketing rep for use)
• Short Form Health Questionnaire & Medical history (Spanish)
• Group Dental Application

Group Size 100+

• Application for Enrollment/Waiver (Print and complete two copies of this PDF form. Sign one form and send it in, save the second for your records.)
• Application for Enrollment/Waiver (Spanish)
• Group Dental Application

Authorization Forms

• Agent Automatic Deposit Authorization Form
• Authorization to Disclose Protected Health Information
• Authorization to Disclose Protected Health Information (Spanish)

Claim Form

• Member Reimbursement Claim Form

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

• Health Questionnaire (must accompany SEP form)
• Special Enrollment Period (SEP) Form
• Special Enrollment Period (SEP) Form (Spanish)

Miscellaneous Member Forms

• Change Form "E-27 " (Print and complete two copies of this PDF form. Sign one form and send it in, save the second for your records)
• Change Form "E-27" (Spanish)
• Affidavit of Qualifying Incapacitated Dependent Eligibility
• Conversion Application
• Incident Report
• Michelle's Law - Dependent Child Certification
• 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

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