Medicare Product Forms

• Authorization for Disclosure of Protected Health Information (PDF)
• Regence MedAdvantage (PPO)
  • Enrollment Form 2011
• Regence Life and Health Medicare Script (PDP)
  • Enrollment Form 2011

Individual Product Forms

• Idaho Surepay Authorization (PDF)

Group Product Forms

Important Note: 2012 Product Changes
Effective January 1, 2012, some Regence products will be discontinued or closed to groups sized 2-99. Please see the Product Transition Page for more information.

• 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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