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

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

• Group Master Applications
  • Groups 2-99 Employees
  • Groups 100+ Employees
• 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
• Application for Enrollment/Change (PDF)
• 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)

Employee Benefit Brochure Inserts

• Medical and dental benefit brochure insert for Coordination of Benefits (COB) Administrative Rule change (PDF) for claim dates of service on or after September 1, 2009.
  Innova, Engage, Activate, HSA Healthplan 2.0, Encore, and Expressions