Individual Product Forms

• Application and cover sheet (PDF) for Regence Summit^SM, Regence NowSelect and the Regence Individual Health Savings Account
• Individual and Family Application Checklist
• Notice of Privacy Practices
• Application Update Form (PDF)
• Application for Protection Plus Plan (PDF) (Washington)
• Proxy Notice (PDF)
• Parental Consent Form (PDF)
• Multiple Coverage Inquiry Form (PDF)
• Automatic Withdrawal Form (PDF)
• Policy Change Request
• Washington Deductible Change Form (PDF)
• Request to Add a Newborn to Your Policy (PDF)

Medicare Product Forms

• Application for Medicare Supplement and Senior Selection (PDF)
• Policy Change Request Form for Medicare Supplement and Senior Selection (PDF)
• Authorization for Disclosure of Protected Health Information (PDF)
• Regence MedAdvantage (PPO)
  • Enrollment Forms
    • 2009
    • 2010
  • Short Enrollment Forms (for members upgrading their plan)
    All pages of this form must be given to inquiring or applying individuals.
    • 2009
    • 2010
• Regence Life and Health Medicare Script (PDP)
  • Enrollment Forms
    • 2009
    • 2010
  • Short Enrollment Forms (for members upgrading their plan)
    All pages of this form must be given to inquiring or applying individuals.
    • 2009
    • 2010

Group Product Forms

• Group Proposal Request Form (2-50 and 51-99 Eligible Employees)
• Small Group Application (2-50 Eligible Employees)
• Application Update Form (PDF)
• Large Group Application for Enrollment (PDF) (Experience-rated or ASC)
• Application for Enrollment (PDF) (51-99 employees)
• Group Master Application (GMA) (2-99 employees)
• Waiver Form (Group Size 2-50)
• Employee Certification (PDF)
• Multiple Coverage Inquiry Form (PDF)
• Agent Letter of Record (PDF)
• Willamette Dental Group Application (PDF)
• Willamette Dental Enrollment and Change of Information (PDF)
• Request to Add a Newborn to Your Policy (PDF)
• Affidavit of Qualifying Incapacitated Dependent Eligibility

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