For Activate^SM, Innova^SM & Engage^SM only

Back to forms for all other group products.

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

Group Master Applications / Solicitud Grupal Principal

• Effective dates 8/1/08 and beyond
  • Oregon, 2-99 employees (PDF)
  • Oregon, 100+ employees (PDF)
  • Clark County, Washington, 2-99 employees (PDF)
  • Clark County, Washington, 100+ employees (PDF)
• Spanish (8/1/08 versions coming soon)
  • Oregon, 2-99 employees (Spanish) (PDF)
  • Clark County, Washington, 2-99 employees (Spanish) (PDF)

Other Enrollment Forms

• Waiver Form / Formulario de renuncia
  • Oregon (PDF)
  • Clark County, Washington (PDF)
• Application for Enrollment/Change / Solicitud de inscripción/cambio
  • Oregon (PDF)
  • Clark County, Washington (PDF)
  • Oregon (Spanish) (PDF)
  • Clark County, Washington (Spanish) (PDF)
• COBRA Qualification Worksheet (PDF)
• SurePay Authorization (PDF)
  
  
• Employer Center & Online Enrollment
  • Online Enrollment Set-Up Checklist (PDF)
  • Employer Center Setup Form (PDF)
    To add access to Employer Center outside of initial enrollment
    or at your group’s renewal anniversary.

Request for Proposal

• Request for Group Proposal (PDF)

Claim Forms

• Prescription Mail Order (PPS) Form (PDF)
• Walgreens Prescription Mail Order Form (PDF)

Authorization Forms

• Authorization for Use and Disclosure of Protected Health Information (PDF)
• Authorization to Disclose Health Information (Spanish) (PDF) / Autorización para Divulgar Información Protegida de Salud
  • Oregon (Spanish) (PDF)
  • Clark County, Washington (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, Washington (PDF)
• Dual Option Matrices & Guidelines
  • Oregon
    • Innova/Engage Matrix (Groups 25-50) (PDF)
    • Activate/Innova/Engage Matrix (Groups 25-50) (PDF)
    • Activate/Innova/Engage Guidelines (Groups 51+) (PDF)
  • Clark County, Washington
    • Activate/Innova/Engage Guidelines (Groups 51+) (PDF)
• Enrollment Requirements and Rating Assumptions
  • Group size 2-25 (Oregon) (PDF)
  • Group size 26-99 (Oregon) (PDF)
  • Group size 2-50 (Clark County, Washington) (PDF)
  • Group size 51-99 (Clark County, Washington) (PDF)

Verification Forms

• Affidavit of Qualifying Incapacitated Dependent Eligibility (PDF)
• Affidavit of Qualifying Domestic Partnership (PDF)
• Statement of Termination of Domestic Partnership (PDF)