See other forms for Asuris Advance^SM and Preferred Plans

Note: These forms are the most common ones that you'll need. Not all online forms are ready yet for these new products, but we'll add them here as they become available.

• Group Master Applications - Effective 04/01/10 through 06/01/10
  • Groups 2-99 Employees
    
  • Groups 100+ Employees
• Group Master Applications - Effective 07/01/10 and Beyond
  • Groups 2-99 Employees
  • Groups 100+ Employee
• Dual Option Matrices & Guidelines - Effective 07/01/10 and Beyond
  • Embark/Vantage/HSA 2.0 Dual Option Matrix (Groups 10-50) (PDF)
  • Embark/Vantage Dual Option Matrix (Groups 25-50) (PDF)
  • Embark/Vantage/Motivate Dual Option Matrix (Groups 25-50) (PDF)
  • Dual Option Guidelines (Groups 51+)
• Application for Enrollment/Change
• Application for Enrollment/Change (Spanish) (PDF)
• Waiver Form
• Affidavit of Qualifying Domestic Partnership
• Affidavit of Qualifying Incapacitated Dependent Eligibility
• Online Enrollment Set-Up Checklist (PDF)
• Employer Center Setup Form
• Surepay Authorization Form
• Authorization for Use and Disclosure of Protected Health Information (PDF)
• Group Administrator Manual (PDF) For Motivate, Embark Vantage and HSA 2.0 plans only. Your first resource in administering the coverage selected by your company. General information about enrollment, billing, and appeals procedures.
• Medical and dental benefit brochure insert for Coordination of Benefits (COB)
• Administrative Rule change for claim dates of service on or after September 1, 2009
  For Embark, Vantage, Motivate, HSA Healthplan 2.0, Aspire, and Enhance

Spanish Language Forms / Formularios en Español
Currently available for Motivate, Embark and Vantage plans only

• Waiver Form / Formulario de renuncia
• Authorization to Disclose Health Information / Autorización para Divulgar Información Protegida de Salud