Forms

For Employers

• Employer Application
  (for groups effective January 2021 and beyond)
• Employer Application
  (for groups effective August 2020 through December 2020)
• ConnectiCare Benefits, Inc. (CBI) Small Group Enrollment Form
  (for groups effective January 2021 and beyond)
• Rules and Requirements
• HealthEquity HRA/HSA Setup
• Group Size Certification
• Small Group Information Change
• Direct Debit Form
• Partial Month Termination Credit
• Registration for Online Account Access

For Employees

• Enrollment/Change Form
  (for groups effective January 2021 and beyond)
• Enrollment/Change Form
  (for groups effective August 2020 through December 2020)
• Spanish Enrollment/Change Form
  (for groups effective January 2021 and beyond)
• Spanish Enrollment/Change Form
  (for groups effective August 2020 through December 2020)
• ConnectiCare Benefits, Inc. (CBI) Enrollment/Change Form
  (for groups effective January 2021 and beyond)
• Waiver of Coverage Form
• Mail Order Pharmacy Form
• Out of Network Reimbursement Form
• Transition/Continuity of Care Form
• Domestic Partner Affidavit
• Application for Continuation of Coverage for a Disabled Dependent Child
• Authorization to Use or Disclose Protected Health Information (HIPAA Release Form)
• Language and Non-Discrimination Notice
• Dental Enrollment Form