Forms

Shown below are links to a variety of group benefit and individual insurance forms that may be useful to you. To view and print a form, click on the appropriate link below. To save a form without viewing it, right-click the link and select "Save Target As" or "Save Link As" (depending on your browser).  Then specify a location on your hard drive where you wish to save the form.

The downloadable files listed on these pages are in Adobe Acrobat® PDF format. To view and print them you'll need to have the Adobe Acrobat® Reader installed and properly configured on your computer. To download a free copy of Adobe Acrobat® Reader, click on the icon below.

View Group Benefit Forms

View Individual and Family Forms

Group Benefit Forms

	Enrollment Form (2-50 Employees) Enrollment Form (51+ Employees) Medical Claim Form Dental Claim Form Prescription Drug Claim Form Mail Order Drug Application Form Authorization to Disclose Private Health Information (PHI)
	Enrollment Form Dental Claim Form Authorization to Disclose Private Health Information (PHI)
	Enrollment Form-Group Prescription Drug Claim Form Mail Order Drug Application Form Authorization to Disclose Private Health Information (PHI)
	Enrollment Form (2-150 Employees) Spanish Instructions for Enrollment Form (2-150 Employees) Enrollment Change Form Medical Claim Form Dental Claim Form International Claim Form Prescription Drug Claim Form PrimeMail Member Flier (PPO and HMO) PPO Mail Order Drug Application Form PrimeMail Registration Form (PPO) PrimeMail Registration Form (HMO) Prime Mail Fax Form Walgreens Mail Service Member Brochure (HMO) Walgreens HMO Mail Service Registration and Order Walgreens HMO Mail Service Physician Fax Form Employer Acknowledgement Form Benefit Program Application Change Form (2-150) Authorization to Disclose Private Health Information (PHI) (Group) Employer New Business Forms New Business Checklist (2-150) Benefit Program Application (2-150) Benefit Plan Selection Form (2-150) Group Information Form (2-150) Medicare As Secondary Payer Form (2-150)
	Enrollment Form (Non-Medical Coverages) Dependent Eligibility Certification Form Evidence of Insurability Form (Life) Evidence of Insurability (Non-med) Dental Claim Form Short-Term Disability Claim Form LTD CLaim Form Attending Physician's Statement Beneficiary Designation/Claim Form Authorization to Disclose PHI
	Medical Enrollment Form (2-50) Medical Enrollment Form (51+) Authorization to Disclose Private Health Information (PH)I
	Employee Enrollment Form Evidence of Insurability Form Authorization to Release Private Health Information (PHI) Dental Claim Form Beneficiary Designation Form Life Insurance Conversion Brochure Life Insurance Conversion Form
	Enrollment Form Statement of Health Form Dental Claim Form Short-Term Disability Claim Form Beneficiary Designation Form Change Form
	Enrollment Form (2-50) Enrollment Form (New 51-99) Medical Claim Form Dental Claim form Rx Claim Reimbursement Form Mail Order Drug Application Form Authorization to Disclose PHI

Individual and Family Forms and Plan Summaries

	Individual and Family Application Managed Choice and PPO 2500 Managed Choice and PPO 3500 Managed Choice and PPO 5000 Managed Choice and PPO Value 3000 Managed Choice and PPO Value 5000 Managed Choice and PPO High Deductible 3500 HSA Managed Choice and PPO High Deductible 5000 HSA Dental PPO Max Plan
	Application Form Applicant Checklist Comprehensive Portfolio Brochure Condition-Specific Deductbles Brochure Suite Solutions Brochure Short-Term Medical Six-Month Brochure and Application Short-Term Medical Optional Benefits Brochure
	Application Form Request for Underwriting Opinion Request for Change in Coverage Request for Change in Coverage (HSA) Authorization to Disclose PHI (Ind) Payment Authorization Agreement Medicare Supplement Application Medicare Supplment Checklist MedSelect Hospital Listing SelectBlue Plan Summary SelectBlue Advantage Plan Summary BlueChoice Select Plan Summary BlueValue Plan Summary BlueEdge Plan Summary BlueEdge 5,000 Plan Summary BlueCare Dental PPO Plan Summary SelecTemp Short-Term Medical Plan Summary SelecTemp Short-Term Medical Plan Application
	Checklist, Application and Disclosure Forms Consent for Release of Personal & Health Information HumanaOne Enhanced HSA 100% Plan Summary Humana One Enhanced Copay 80% Plan Summary HumanaOne Value 100% Plan Summary HumanaOne Short-Term Medical 100%/75% Plan Summary HumanaOne Optional Benefits Summary HumanaOne Short-Term Medical 80%/60% Plan Summary Humana Short-Term Medical Application
	Medicare Supplement Product Booklet with Application Form Choosing a Medigap Policy (Centers for Medicare and Medicaid Services)