Forms: Activate^SM, Innova^SM, Engage^SM & HSA Healthplan 2.0^SM

See other forms for Regence Revive^SM, Regence Select, Regence Chamber Select and other plans

• Group Proposal Request Form (Groups 2 to 99 eligible employees)
  For 100+ groups, please contact us.



• Group Master Applications
  • For effective dates 1/1/2010 and beyond
  • Groups 2-99 Employees
  • Groups 100+ Employees
• Waiver Forms
• For effective dates 1/1/2010 and beyond
• Groups 2-50 (PDF)
• Groups 51+ (PDF)
• Employee Applications
  • Small Employer Application (Groups 2-50) (PDF)
  • Application for Enrollment/Change (Groups 51-99) (PDF)
  • Application for Enrollment/Change (Groups 100+ Fully Insured)
  • Application for Enrollment/Change (Groups 100+ Self Insured)
• Affidavit of Qualifying Incapacitated Dependent Eligibility (PDF)
• Affidavit of Qualifying Domestic Partnership (PDF)
  
  
• Dual Options & Guidelines
  • Activate/Innova/Engage Dual Option Matrix (Groups 25-50) (PDF)
  • Innova/Engage Dual Option Matrix (Groups 15-50) (PDF)
  • Innova/Engage/HSA 2.0 Dual Option Matrix (Groups 10-50) (PDF)
  • Activate/Innova/Engage/HSA Healthplan 2.0 Dual Option Guidelines (Groups 51+) (PDF)
• Employee Certification (Groups 2-50) (PDF)
• Authorization to Disclose Protected Health Information (PDF)
• SurePay Form


• 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

• For effective dates 1/1/2010 and beyond / Para las fechas de vigencia y más allá de 1/1/2010
• Waiver Form (Group Size 2-50)/Formulario de renuncia (Tamaño del grupo 2 a 50)
• Waiver Form (Group Size 51-99)/Formulario de renuncia (Tamaño del grupo 51 a 99)
• Authorization to Disclose Health Information/Autorización para Divulgar Información Protegida de Salud
• Application for Enrollment/Change (PDF)