Employee Forms and Applications, including Enrollment Spreadsheet Tool (groups 1-100)

Form		Download
Enrollment Spreadsheet		2022 - Q1 / Q2 2021 - Q4 2021 - Q3
Guide to Enrollment Spreadsheet		Download
Enrollment Spreadsheet Flier
Employee Application Employees should complete this form to enroll in a group medical plan, group vision plan, or group term life policy. For employee enrollments to a new or existing employer group. As a reminder, once a fillable PDF is saved to the desktop, you cannot go back and make changes.
	2022 Employee Application New/renewing groups effective January 1 through June 30, 2022	English (Fillable PDF, 1.23 MB) Spanish (Fillable PDF, 1.46 MB)
	2021 Employee Application New/renewing groups effective October 1, 2021	English (Fillable PDF, 2.3 MB) Spanish (Fillable PDF, 2.3 MB)
	2021 Employee Application New/renewing groups effective July 1, 2021	English (Fillable PDF, 2.3 MB) Spanish (Fillable PDF, 2.4 MB)
	2021 Employee Application New/renewing groups effective April 1, 2021	English (Fillable PDF) Spanish (Fillable PDF)
	2021 Employee Application New/renewing groups effective January 1, 2021	English (Fillable PDF) Spanish (Fillable PDF)
Subscriber Change Request Employees can change personal information, change plans during open enrollment, enroll new dependents, or cancel dependents (include Refusal or Cancellation of Personal Coverage form).
	2022 Subscriber Change Request New/renewing groups effective January 1 through June 30, 2022	English (Fillable PDF, 1.2 MB) Spanish (Fillable PDF, 1.15 MB)
	2021 Subscriber Change Request New/renewing groups effective October 1, 2021	English (Fillable PDF, 2.1 MB) Spanish (Fillable PDF, 2.1 MB)
	2021 Subscriber Change Request New/renewing groups effective July 1, 2021	English (Fillable PDF, 2.2 MB) Spanish (Fillable PDF, 2.2 MB)
	2021 Subscriber Change Request New/renewing groups effective April 1, 2021	English (Fillable PDF) Spanish (Fillable PDF)
	2021 Subscriber Change Request New/renewing groups effective April 1, 2021	English (Fillable PDF) Spanish (Fillable PDF)
	2021 Subscriber Change Request New/renewing groups effective January 1, 2021	English (Fillable PDF) Spanish (Fillable PDF)
Refusal of Coverage Employees complete this form if they, their spouse/domestic partner, or other dependents refuse their employer’s medical or dental plan coverage
	2022 Refusal of Coverage form New/renewing groups effective January 1, 2022	English (Fillable PDF, 567 KB)
	2021 Refusal of Coverage form New/renewing groups effective October 1, 2021	English (Fillable PDF, 1.7 MB)
	2021 Refusal of Coverage form New/renewing groups effective July 1, 2021	English (Fillable PDF, 1.7 MB)
Continuity of Care program brochure		English Spanish Chinese Vietnamese Hindi Korean
Request for Continuity of Care Service for established members and new enrollees Members of HMO-only groups with qualifying conditions may be able to complete care with a non-network provider.		English Spanish Chinese Vietnamese Hindi Korean
Authorization for the use or disclosure of health information		English Spanish Chinese Vietnamese Hindi Korean
Continuity of care notice for new HMO enrollees Important notice for new HMO enrollees.		Download
Declaration of Disability of Over Age-Dependent Children For enrolled dependent children who normally lose their eligibility because of age but who have a physical or mental disabling injury.		English Spanish
Waiver of Premium Claim Form – Life If a member becomes totally disabled, the life premium may be waived.		Download
Premium Only Plan (POP) HealthEquity's POP lets employers cut payroll taxes without cutting payroll. If an employer requires employees to contribute to the cost of their insurance, a Section 125 POP allows them to do so with pre-tax dollars.		Download
CVS Mail Order Form		Download (Fillable PDF)

Employee Forms and Applications, including Enrollment Spreadsheet Tool (groups 1-100)

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