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

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

Future Automation Enhancement
To expedite processing, we are adding scanner targets and barcodes to fillable forms. These changes will not impact the data or information fields you complete.

• Group Master Applications
  • Effective 07/01/09 to 12/31/09
• Groups 2-99 Employees
• Groups 100+ Employees
• Effective 01/01/10 and beyond
  • Groups 2-99 Employees
  • Groups 100+ Employee
• Spreadsheet Enrollment Procedure and Template (Groups 2+)
• Dual Option Matrices & Guidelines
• Effective 07/01/09 and beyond:
  • 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)
  • Dual Option Guidelines (Groups 51+) (PDF)
• Request for Proposal (PDF)
• Application for Enrollment/Change (PDF)
• Delayed Enrollment Exception Request
• Waiver Form
• Affidavit of Qualifying Domestic Partnership (PDF)
• Affidavit of Qualifying Incapacitated Dependent Eligibility (PDF)
• 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)