Forms: Evolve^SM Individual Plans and Forms: Employee Choice^SM, Innova^SM, Regence HSA Healthplan 2.0^SM and Regence Revive^SM Group Plans and Regence Bridge Medigap Plans.

See other forms for Medicare and other plans.

Please note that the Engage^SM group plan is closed for new enrollment as of January 1, 2012. Please contact your account executive for forms relating to that plan

INDIVIDUAL

• Application: Individual Application Cover Sheet (PDF) and Idaho Individual Application (PDF) – both documents are required
• EFT/Surepay Form  (PDF)
• Domestic Partner Affidavit (PDF)
• Affidavit of Incapacitated Dependent (PDF)
• Transfer Rate Review Form (PDF)
• Evolve Plan Change Request (PDF)
• Authorization to Continue Coverage (PDF)

MEDIGAP

• Regence Bridge Medigap Application (PDF)
• Regence Bridge Medigap Outline of Coverage (PDF)
• Regence Bridge Medigap Notice of Replacement Form (PDF)

GROUP

• Cancellation Request Form  
   
• Group Proposal Request Form (Groups 2 to 99 eligible employees)
  For 100+ groups, please contact us.
• New Small Group Quote & Enroll Checklist (PDF)
  
  
• Group Master Applications
  • For effective dates of 7/1/2012 and beyond
    • Groups 2-99 Employees (Fillable PDF)
    • Groups 100+ Fully Insured (Fillable PDF)
    • Groups 100+ Self Insured (Fillable PDF)
  • For effective dates PRIOR to 7/1/2012
    • Groups 2-99 Employees (Fillable PDF)
    • Groups 100+ Fully Insured (Fillable PDF)
    • Groups 100+ Self Insured (Fillable PDF)
       
• Renewal and Maintenance Change Request Form (Fillable PDF)



• Spreadsheet Enrollment Procedure and Template (Groups 100+)
   
• Waiver (Groups 51+) (PDF)
   
• Employee Applications
  • Small Employer Application (Groups 2-50)
  • Small Employer Application (Groups 2-50) (Spanish) (PDF)
  • Application for Enrollment/Change (Groups 51-99) (PDF)
  • Application for Enrollment/Change (Groups 100+ Fully Insured) - Eff. 1/1/2012 and beyond
  • Application for Enrollment/Change (Groups 100+ Self Insured) - Eff. 1/1/2012 and beyond
• Affidavit of Qualifying Incapacitated Dependent Eligibility (PDF)
• Affidavit of Qualifying Domestic Partnership (PDF)
  
  
• Employee Certification (Groups 2-50) (PDF)
• Authorization to Disclose Protected Health Information (PDF)
• Surepay Form

• Dual Options & Guidelines
• Dual Option Matrix for HSA Healthplan 2.0 and Innova (PDF)
• Dual Option Matrix for Innova (PDF)
• Dual Option Guidelines for 51 to 99 and 100+ Groups (PDF)

• Employer Center & Online Enrollment
  • Online Enrollment Set-Up Checklist (Groups 100+) (PDF)
  • Employer Center Setup Form
To add access to Employer Center outside of initial enrollment or at a group's renewal anniversary.

Spanish Language Forms / Formularios en Español

• Authorization to Disclose Health Information/Autorización para Divulgar Información Protegida de Salud
• Application for Enrollment/Change (PDF)

• Employee Choice Election Form