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

See other forms for BlueChoices^SM and Regence HSA Healthplan

Note: These forms are the most common ones that you'll need. Not all online forms are ready yet for these new products, but we'll add them here as they become available.

Enrollment Forms Necessary to Enroll a Group
Agent's New Group Enrollment Checklist (PDF)

Group Master Applications

• Oregon - 2-99 employees
• Oregon - 100+ employees
• Oregon - Administrative Services Contract
• Clark County, WA - 2-99 employees
• Clark County, WA - 100+ employees
• Clark County, WA - Administrative Services Contract

Other Enrollment Forms

• Spreadsheet Enrollment Procedure and Template (Groups 2+)
• Waiver Form / Formulario de renuncia
  • Oregon
  • Oregon - Spanish
  • Clark County, WA
  • Clark County, WA - Spanish
• Application for Enrollment/Change
  • Oregon
  • Oregon - Spanish (PDF)
  • Clark County, WA
  • Clark County, WA - Spanish
• COBRA Qualification Worksheet
• SurePay Authorization



• Employer Center & Online Enrollment
  • Online Enrollment Set-Up Checklist (PDF)
  • Employer Center Setup Form
    To add access to Employer Center outside of initial enrollment or at a group’s renewal anniversary.

Request for Proposal

• Request for Group Proposal

Claim Forms

• Prescription Mail Order (PPS) Form (PDF)

Authorization Forms

• Authorization for Use and Disclosure of Protected Health Information (PDF)
• Authorization to Disclose Health Information / Autorización para Divulgar Información Protegida de Salud
  • Oregon - Spanish (PDF)
  • Clark County, WA - Spanish (PDF)

Literature

• Washington Patient Bill of Rights Disclosure Packet
  • Traditional/PPO (PDF)
  • Regence Life and Health (PDF)
• Notices of Privacy Practices
  • Regence BlueCross BlueShield of Oregon (PDF)
  • Regence Life and Health (PDF)
• SEHI Disclosure Statement (PDF)
• TruVision™ (PDF)

Miscellaneous

• Annual Census Form
  • Oregon (PDF)
  • Clark County, WA (PDF)
  
  
• Dual Option Matrices & Guidelines
  Effective dates 7/1/09 and beyond
  • Oregon - Regence HSA Healthplan 2.0/Innova/Engage Matrix (Groups 10-50) (PDF)
  • Oregon - Innova/Engage Matrix (Groups 25-50) (PDF)
  • Oregon - Activate/Innova/Engage Matrix (Groups 25-50) (PDF)
  • Oregon - Dual Option Guidelines (Groups 51+) - Please contact your sales team for assistance in customizing a suitable pairing of plans.
  • Clark County, WA - Regence HSA Healthplan 2.0/Innova/Engage Matrix (Groups 10-50) (PDF)
  • Clark County, WA - Innova/Engage Matrix (Groups 25-50) (PDF)
  • Clark County, WA - Activate/Innova/Engage Matrix (Groups 25-50) (PDF)
  • Clark County, WA - Dual Option Guidelines (Groups 51+) - Please contact your sales team for assistance in customizing a suitable pairing of plans.
• Enrollment Requirements and Rating Assumptions
• Oregon - Group size 2-25 (PDF)
• Oregon - Group size 51-99 (PDF)
• Clark County, WA - Group size 2-50 (PDF)
• Clark County, WA - Group size 51-99 (PDF)
• Oregon and Clark County Small Group Verification (PDF)

Verification Forms

• Affidavit of Qualifying Incapacitated Dependent Eligibility
• Affidavit of Qualifying Domestic Partnership
• Statement of Termination of Domestic Partnership
• Business Owner/Employee Certification (Oregon)
• Business Owner/Employee Certificaton (Clark Co. WA)