Forms: 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

Group Master Applications

• Oregon—2-50 employees RENEWAL
  • Effective date 4/1/2012 through 6/30/2012
  • Effective date 7/1/2012 and beyond
• Oregon—2-99 employees
• Effective date 4/1/2012 through 6/30/2012
• Effective date 7/1/2012 and beyond
  
• Oregon—100+ employees
• Effective date 1/1/2012 through 6/30/2012
• Effective date 7/1/2012 and beyond
  
• Oregon—Administrative Services Contract
• Effective date 1/1/2012 through 6/30/2012
• Effective date 7/1/2012 and beyond
  
• Clark County, WA—1-99 employees
  • Effective date 1/1/2012 through 6/30/2012
  • Effective date 7/1/2012 and beyond
    
• Clark County, WA—100+ employees
  • Effective date 1/1/2012 through 6/30/2012
  • Effective date 7/1/2012 and beyond
    
  • Effective date 1/1/2012 through 6/30/2012 (For Grandfathered Groups Only)
  • Effective date 7/1/2012 and beyond (For Grandfathered Groups Only)
    
• Clark County, WA—Administrative Services Contract
  • Effective date 1/1/2012 through 6/30/2012
  • Effective date 7/1/2012 and beyond
    
  • Effective date 7/1/2011 and beyond (For Grandfathered Groups Only)

Renewal and Maintenance Change Request and Group Change Notification Forms

• Oregon
  • Renewal and Maintenance Change Request - Effective date 8/01/2011 through 6/30/2012
  • Renewal and Maintenance Change Request - Effective date 7/1/2012 and beyond
  • Group Change Notification - Effective date 7/1/2012 and beyond

• Clark County, WA
  • Renewal and Maintenance Change Request - Effective date 8/01/2011 through 6/30/2012
  • Renewal and Maintenance Change Request - Effective date 7/1/2012 and beyond
  • Group Change Notification - Effective date 7/1/2012 and beyond

Other Enrollment Forms

• Employee Choice Request Form
• Spreadsheet Enrollment Procedure and Template (Groups 2+)
• Waiver Form
  • Oregon
  • Clark County, WA
• Application for Enrollment/Change
  • Effective 1/1/2012 and beyond
    • Oregon
    • Clark County, WA (English Fillable PDF)
    • Clark County, WA (Spanish Fillable PDF)
• Application for Enrollment/Change (Groups 100+ Self Insured)
  • Effective 1/1/2012 and beyond
    • Oregon
    • Clark County, WA

• Cancellation Request Form

• Continuation Application
  • Oregon
  • Clark County, Washington
     
• Group Roster
• 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 your group’s renewal anniversary.

Step-by-Step Guide

• Employee Choice Step-by-Step Guide (PDF)

Request for Proposal

• Request for Group Proposal

Claim Forms

• Prescription Mail Order (PPS) Form (PDF)
• Filing a Claim (PDF)—This flyer explains what to do when you receive a bill from your provider.
• Medication Claim Form (PDF) - Use this form for reimbursement when the pharmacy did not have your member card information to process your claim online. Applicable to plans that allow the pharmacy to submit claims online for you and collect a copay at time of purchase.
• Durable Medical Equipment & Medical Supply Claim Form—Use this form to submit a durable medical equipment claim for reimbursement on PPO and Traditional plans.
• Prescription Medication Claim Form (PDF)—Submit claims for durable medical equipment or prescription plans that require members to pay out of pocket and submit for reimbursement.

Authorization Forms

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

Literature

• Notices of Privacy Practices
  • Regence BlueCross BlueShield of Oregon (PDF)
• SEHI Disclosure Statement (PDF)

Miscellaneous

• Annual Census Form
  • Oregon (PDF)
  • Clark County, Washington (PDF)
  
  
  • Oregon and Clark County Small Group Verification (PDF)
  • Verification of Employment (Oregon) (PDF)
  • Verification of Employment (Clark Co., WA) (PDF)
• Dual Option Matrices & Guidelines
  • Oregon Consolidated Dual Option Matrix for HSA Healthplan 2.0 and Innova For Groups of 10-50 Employees (PDF) Eff. 1/1/12 and beyond
  • Oregon Consolidated Dual Option Matrix for HSA Healthplan 2.0 and Innova For Groups of 25-50 Employees (PDF) Eff. 1/1/12 and beyond
  • Oregon—Dual Option Guidelines (Groups 51-99 and 100+) (PDF) —Please contact your sales team for assistance in customizing a suitable pairing of plans
  • Clark County, WA Consolidated Dual Option Matrix for HSA Healthplan 2.0 and Innova For Groups of 10-50 Employees (PDF) Eff. 1/1/12 and beyond
  • Clark County, WA Dual Option Matrix for HSA Healthplan 2.0 and Innova For Groups of 25-50 Employees (PDF) Eff. 1/1/12 and beyond
  • Clark County, WA—Dual Option Guidelines (Groups 51-99 and 100+)—Please contact your sales team for assistance in customizing a suitable pairing of plans
• 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)
• Exclusion Period for Pre-Existing Condition
  • Oregon (PDF)
  • Clark County, WA (PDF)

Verification Forms

• Affidavit of Qualifying Incapacitated Dependent Eligibility
• Affidavit of Qualifying Domestic Partnership
• Statement of Termination of Domestic Partnership