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

See other forms for the 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. 07/15/2009) 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 (prior to 7/1/2009)
• 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)
• 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)
• Small Group Proposal Checklist

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
• 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 Protected Health Information
• Authorization to Disclose Protected Health Information (Spanish)

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
• 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 Protected Health Information
• Authorization to Disclose Protected Health Information (Spanish)

MISCELLANEOUS MEMBER FORMS

• Affidavit of Qualifying Incapacitated Dependent Eligibility
• Affidavit of Qualifying Domestic Partnership
• Incident Report
• Member Reimbursement Claims Form
• Prescription Medication Mail-order Form located at www.RegenceRx.com
• Michelle's Law - Dependent Child Certification

MISCELLANEOUS EMPLOYER FORMS

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

COBRA/UTAH mini-COBRA CONTINUATION

• COBRA booklet
• COBRA General Notice
• COBRA Election Notice & Form
• COBRA Notice of Termination
• COBRA Notice of Unavailability
• COBRA, UTAH mini-COBRA/STATE CONTINUATION or USERRA
• UTAH mini-COBRA CONTINUATION COVERAGE ELECTION NOTICE
• For fillable COBRA General 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

Member Notices

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