• Individual Plans
  
• Medicare Advantage (PPO) and Part D Prescription Plans
  
• Regence Bridge Medigap Plans
  
• Claim Forms
  
• Miscellaneous Forms

Please provide your client with all materials in each product section for a complete packet.

Individual Plans

• Regence Evolve Pre-Sale Brochure (PDF)
  • Oregon
  • Clark County, WA

• Application (PDF)
  • Oregon (PDF) Eff. 1/1/2013 and Beyond
  • Clark County, WA (PDF) Eff. 1/1/2013 and Beyond
  Health Questionnaire (PDF) (Clark County, WA)
  WSHIP Health Questionnaire Exception Instructions (PDF) (Clark County, WA)
   
• Rate Sheet (PDF)

  Current	Archived Rates
  Clark County, WA - Eff. December 1, 2012 PDX Oregon Select - Eff. December 1, 2012 (Portland Metropolitain Area) Oregon Evolve - Eff. December 1, 2012 (Outside Portland Metropolitain Area)	10/1/2011 and beyond - OR Evolve rates 8/1/2011 and beyond - Clark County, WA 10/1/2011 and beyond - OR Evolve rates including Plus and Core $1,000 rates 2/1/2011 and beyond - OR Evolve rates OR Evolve rates: July 1, 2010 to January 31, 2011 3rd Qtr. 2010 - Oregon 2nd Qtr. 2010 - Oregon 1st Qtr. 2010 - Oregon 3/1/2010 through 2/28/2011 - Clark County, WA

• EFT/Surepay Form (PDF)
  • Oregon
  • Clark County, WA
     
• Domestic Partner Affidavit (PDF)
  • Oregon
  • Clark County, WA
• Affidavit of Incapacitated Dependent (PDF) (Oregon)
   
• Non-smoker Certification Form (PDF) (Clark County, WA)
   
• Evolve Plan Change Form (Fillable PDF)
  • Oregon Eff. through 10/31/2012
  • Oregon Eff. 11/1/2012 and Beyond
  • Clark County, WA

Medicare Advantage (PPO) and Part D Prescription Plans

These forms have moved, please click the link above and bookmark the page.

Regence Bridge Medigap Plans - Coverage Effective 6/1/2010

These forms have moved, please click the link above and bookmark the page.

• Durable Medical Equipment & Medical Supply Claim Form
   
• Prescription Medication Form
   
• Prescription Mail Order Form (PDF)

• Scope of Appointment (Medicare Plans)
   
• Agent of Record Addition Form
   
• Agent of Record Change Form

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