Forms: Innova^SM, Engage^SM, Regence BluePoint, Regence Employee Choice^SM & HSA Healthplan 3.0^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.

Groups
For more information on Regence plans click here.

Small Groups (2-50)

• Member Enrollment
  • Utah Small Employer Health Insurance Application (rev. 10/1/2010)
    • English (Fillable PDF)
    • Spanish (Fillable PDF)
  • The Small Employer Application Cover Sheet must accompany the Application for new hires in existing Regence groups and current members selecting continuation coverage
    
    • Small Employer Application Cover Sheet (Fillable PDF) Eff. 1/1/12 and beyond
• Group Master Application (rev. 1/1/12) (Fillable PDF) For groups effective through 6/1//2012
• Group Master Application (rev. 7/1/12) (Fillable PDF) For groups effective 7/1/2012 and after
• Renewal and Maintenance Change Request (7/1/12)
• Small Group Proposal Checklist
• Employee Choice Request Form

Medium Groups (51-99)

• Application for Enrollment/Change Eff. 1/1/12 and beyond
  • English (Fillable PDF)
  • Spanish (Fillable PDF)
• Waiver Form (Groups 51+) (Fillable PDF)
• Group Master Application (rev. 1/1/12) (Fillable PDF) For groups effective through 6/1/2012
• Group Master Application (rev. 7/1/12) (Fillable PDF) For groups effective 7/1/2012 and after
• Renewal and Maintenance Change Request (7/1/12)
• 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 Eff. 1/1/12 and beyond
  • English (Fillable PDF)
  • Spanish (Fillable PDF)
• 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) For groups effective through 6/1/2012
  • Group Size 100+ (rev. 7/1/12) (Fillable PDF) For groups effective 7/1/2012 and after
  • Administrative Services Contract (rev. 1/1/12) (Fillable PDF) For groups effective through 6/1/2012
  • Administrative Services Contract (rev. 7/1/12) (Fillable PDF) For groups effective 7/1/2012 and after
• Renewal and Maintenance Change Request (7/1/12)
• 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
  • 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