| Forms |
Descriptions |
| NEW LARGE GROUPS 100+ (BlueChoices only) |
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Use these forms to enroll a new group of 100+ or a new member on an existing BlueChoices large group plan. |
| MEMBER FORMS & NOTICES |
| New Member enrollment for existing BlueChoices and Regence HSA Healthplan Groups |
Group Size 2-50
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Member enrollment for current groups of 2-50. All forms must be completed and submitted together. |
Group Size 51-99
- Application for Enrollment/Waiver (Print and complete two copies of this PDF form. Sign one form and send it in and save the second for your records.)
- Short Form Health Questionnaire & Medical History (Contact Marketing rep for use)
- Group Dental Application (PDF)
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Member enrollment on already-existing groups 51-99 |
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.)
- Group Dental Application (PDF)
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Member enrollment on already-existing groups 100+ |
Authorization Forms
- Authorization to Disclose Protected Health Information
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Reimbursement Form
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COBRA/UTAH mini-COBRA CONTINUATION
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Information you need to know about COBRA
Sample Notices
For fillable COBRA General Notices visit www.dol.gov/COBRA
Applications for continuation of benefits
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Special Enrollment Forms
- Change Form "E-27" (Print and complete two copies of this PDF form. Sign one form and send it in and save the second for your records.)
- Special Enrollment Period (SEP) Form
- Group Health Questionnaire (must accompany SEP form)
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Use these forms when an employee experiences a life change, such as adding/deleting dependents, a name change or changes during open enrollment. |
Conversion Application
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For individuals who have exhuasted COBRA or mini-COBRA continuation benefits |
Prescription Medication Mail-order Form
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Miscellaneous Member Forms
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Member Notices
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Employer Forms
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