Forms: Evolve^SM Individual Plans and Innova^SM, HSA Healthplan 2.0^SM and Employee Choice^SM Group Plans and Regence Bridge^SM Medigap Plans.

See other forms for Medicare, Preferred Plan FourFront, Regence HSA Healthplan, Preferred Plan, Selections and other health plans.

INDIVIDUAL

• Regence Evolve Comparison Brochure (PDF)
• Application (PDF)
• Health Questionnaire (PDF)
• Rate Sheet (PDF)
• EFT/Surepay Form  (PDF)
• Domestic Partner Affidavit (PDF)
• Affidavit of Incapacitated Dependent (PDF)
• Non-smoker Certification Form (PDF)
• Evolve Plan Change Form (PDF)
• Authorization to Continue Coverage (PDF)
• Agent of Record Change Form (PDF)

MEDIGAP

• Regence Bridge Application (PDF)
• Regence Bridge Outline of Coverage (PDF)
• Regence Bridge Notice of Replacement Form (PDF)

GROUP

• Cancellation Request Form
  
• Group Master Applications - Eff. 1/1/12 and beyond
  • Groups 1-99 Employees
  • Groups 100+ Employees
  Spreadsheet Enrollment Procedure and Template (Groups 2+)
• Dual Option Guidelines
• 2011 Dual Option Guidelines (Groups 51+) (PDF) - Eff. 7/1/10 through 12/31/11
• 2012 Dual Option Guidelines (Groups 51+) (PDF) - Eff. 01/01/12 and beyond
• Dual Option Matrices
• Eff. 7/1/10 through 12/31/11:
  • Innova/Engage/HSA 2.0 Dual Option Matrix (Groups 10-50) (PDF)
  • Innova/Engage Dual Option Matrix (Groups 25-50) (PDF)
  • Innova/Engage/Activate Dual Option Matrix (Groups 25-50) (PDF)
• Eff. 1/1/12 and beyond:
  • Innova/ HSA 2.0 Dual Option Matrix (Groups 10-50) (PDF)
  • Innova Dual Option Matrix (Groups 25-50) (PDF)
• Request for Proposal (PDF)
• Renewal and Maintenance Change Request
• Application for Enrollment/Change (PDF) Eff. 1/1/12 and beyond
• Application for Enrollment/Change (Groups 100+ Self Insured) Eff. 1/1/12 and beyond
• Delayed Enrollment Exception Request - Coming Soon
• Waiver Form
• Verification of Employment
• Affidavit of Qualifying Domestic Partnership
• Affidavit of Qualifying Incapacitated Dependent Eligibility
• Online Enrollment Set-up Checklist (PDF)
• Employer Center Setup Form
• Surepay Authorization Form
• Authorization for Use and Disclosure of Protected Health Information (PDF)

Spanish Language Forms / Formularios en Español

• Waiver Form / Formulario de renuncia
• Authorization to Disclose Health Information / Autorización para Divulgar Información Protegida de Salud
• Application for Enrollment/Change (Spanish) (PDF)