Forms: Activate^SM, Innova^SM & Engage^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
• Dual Option Matrices
  • Activate/Innova/Engage Matrix (for groups 25-50)
  • Innova/Engage Matrix (for groups 15-50)
• Waiver Form
  • English
  • Spanish
• 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)

• Application for Enrollment/Change
  • English
  • Spanish
• Short Form Health Questionnaire and Medical History Statement
  • English
  • Spanish
• Group Master Application
• Dual Option Guidelines
• Waiver Form
  • English
  • Spanish
• Midsize Group Proposal Checklist
• Online Enrollment Set Up Checklist
• Authorization to Disclose Health Information
• Authorization to Disclose Health Information (Spanish)/ Autorización para Divulgar Información Protegida de Salud

Large Groups (100+)

• Application for Enrollment/Change
  • English
  • Spanish
• Short Form Health Questionnaire and Medical History Statement
  • English
  • Spanish
• Group Master Application
• Dual Option Guidelines
• Waiver Form
  • English
  • Spanish
• Online Enrollment Set Up Checklist
• 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
• Activate New Group Proposal Request (Groups 2-99)
• Activate New Group Proposal Request (Groups 100+)
• Innova & Engage New Group Proposal Request (Groups 2-99)
• Innova & Engage New Group Proposal Request (Groups 100+)