Enrollment Forms Necessary to Enroll a Group

• Application for Group Coverage
• Agent's New Group Enrollment Checklist
• New Enrollment and Change Form
• New Enrollment and Change Form (Spanish)

Enrollment Forms

• Group Roster
• COBRA Qualification Worksheet
• COBRA Enrollment Application
• Continuation Application
  • Oregon
  • Clark County, Washington
• Declination of Coverage
• Declination of Coverage (Spanish)
• New Enrollment and Change Form
• New Enrollment and Change Form (Spanish)

Request for Proposal

• Request for Group Proposal

Claim Forms

• BlueChoices^SM Accidental Death Claim Form
• Prescription Medication Form
• Direct Reimbursement Form
• Durable Medical Equipment Form (Regence Life & Health)
• Durable Medical Equipment & Medical Supply Claim Form
• Prescription Mail Order (PPS) Form
• Walgreens Prescription Mail Order Form

Authorization Forms

• Authorization for Use and Disclosure of Protected Health Information
• Authorization for Use and Disclosure of Psychotherapy Notes

Literature

• BlueChoices Member Guide
• BlueChoices Brochure
• Washington Annual Notification
• Washington Pre-Sale Disclosure List
• Oregon Disclosure Statement

Miscellaneous

• Annual Census Form
  • Oregon
  • Clark County, Washington
• Exclusion Period For Pre-Existing Conditions
• Enrollment Requirements and Rating Assumptions
  • Group size 2-50 (Oregon)
  • Group size 2-50 (Clark County, Washington)
  • Group size 51-99 (Clark County, Washington)

Verification Forms

• Certification of Dependency
• Affidavit of Domestic Partnership
• Certificate of Paternity
• Certification of Placement
  • Oregon
  • Clark County, Washington
• Incapacitated Over Age Dependent Certification
• Statement of Termination of Domestic Partnership

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