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Forms

 

For Employers

  • Small Group Employer Application
    (for groups effective January 2022 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 2022 and beyond)
  • Enrollment/Change Form
    (for groups effective January 2021 through December 2021)
  • CBI Enrollment/Change Form 1-50 Employees
    (for groups effective or renewing January 2021 through December 2021)
  • Spanish Enrollment/Change Form
    (for groups effective January 2022 and beyond)
  • Spanish Enrollment/Change Form
    (for groups effective January 2021 through December 2021)
  • Waiver of Coverage Form
  • Mail Order Pharmacy Form
  • Prescription Drug Reimbursement 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