Click on a form title below to download
and print a copy of the form. Don't see a form you're
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us.
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| ENROLLMENT & CHANGE FORMS |
Employee
Enrollment & Change Form (PDF)
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Use this form to add new members, add or cancel dependents, change a member's
eligibility status or update any other employee information. The form must
be signed by the group administrator. |
| Request to Change Form (PDF) |
Use this form to add or cancel dependents or update any other information.
This form is for existing Asuris Individual Plan members only |
| Asuris
Newborn Application (PDF) |
Use this form to add a Newborn to your Group or Individual
Policy |
| Employee
Cancellation Form (PDF) |
Use this form to cancel employees from an Asuris Northwest Health plan.
Forms must be received by the 10th of the month in order to be excluded
from the next month's billing. The form must be signed by the group administrator. |
| Prior
Coverage Information Request (PDF) |
Employees or dependents who are applying for coverage or who have recently
(within the last 12 months) come onto coverage through Asuris Northwest
Health, and had other medical coverage within six months before starting
Asuris Northwest Health coverage, should complete this form. The information
will be used to establish eligibility for credits on benefit waiting periods. |
| Waiver Form (PDF) |
Employees who decline health care coverage through Asuris Northwest Health
because of other coverage should complete this form. |
Electronic
Funds Transfer Form (PDF)
|
Individual plan members who wish to pay for their coverage through
automatic checking account withdrawal should fill out and return this
form to:
Asuris Northwest Health
P.O. Box 13368
Spokane, WA 99213-3368 |
| VERIFICATION FORMS |
Multiple Coverage Inquiry/Coordination of Benefits
(submit online) |
Use this form to electronically notify us of new coverage, or changes to your other insurance coverage on file. |
Multiple Coverage Inquiry/Coordination of Benefits
(PDF) |
Use this form to notify us of new coverage, or changes to your other insurance coverage on file. |
| Affidavit
of Domestic Partnership (PDF) |
Employees and their domestic partners applying for coverage should complete
this form. Send completed affidavits
with completed Employee Enrollment and Change forms. |
| Affidavit of Qualifying Incapacitated Dependent Eligibility (Fillable PDF) |
Use this form to certify that an eligible dependent child is incapacitated due to medical disability, developmental disability or mental disorder. |
| DISCLOSURES & NOTICES |
| Pre-Sale Disclosure (PDF) |
Pre-sale disclosure statement – Health Care Patient Bill of Rights |
| Post-Sale Disclosure (PDF) |
Post-sale disclosure statement – Health Care Patient Bill of Rights |
Annual Notification
|
Annual notification regarding group
plan coverage. Information for group administrators
to share with all members and dependents. |
| Dental Privacy Practices (PDF) |
Annual notification regarding privacy
practices for dental plans. |
| PRESCRIPTION MEDICATION MAIL-ORDER FORMS |
| Prescription mail-order forms can now be found on the RegenceRx
Member Web site. |
| CLAIMS AND BILLING FORMS |
| Member Claim Form (PDF) |
Use this form to submit claims for covered services, or prescription plans
that require you to pay out of pocket and submit for reimbursement. |
General Incident Report
(Submit Online) |
You may have a claim that has generated a request for an INCIDENT REPORT. Your health contract has exclusion and reimbursement language which allow us to investigate the circumstances surrounding your treatment so that the correct person/company pays for the related charges. If this is a Workers Compensation claim, please see the information below.
Additional questions are also answered in the FAQ section below. |
| Incident
Report (PDF) |
Asuris Northwest Health members will receive this form if
the condition being treated requires investigation for third party liability.
The member has 45 days to complete, sign, and return the form to Asuris
Northwest Health. If the member does not return the form within the required
time period and the services are being denied, the providers’ office
can bill the patient for services. |
| Incident Report FAQ |
Here are some common questions and answers about this form. |
Creditable Coverage Notice Forms |
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| AUTHORIZATION FORMS |
Authorization
to Disclose Protected Health Information (PDF)
|
Authorization for Asuris Northwest Health to disclose health information to a designated
party for a specific purpose. |
| REQUEST FORM |
| Micro
Group (2-3 employees) Request For Proposal (Fillable PDF) |
Businesses with two to three employees can submit this form
to obtain a quote for group medical coverage through Asuris Northwest Health. |
| Case Management Request Form |
Case Management is a service that is available to all members, from birth through the golden years, who may have complex or chronic medical condition(s) or event(s). Case Managers can also assist members who have a potential for future medical conditions. You may complete the online referral request form or call 1(866) 543-5765. |
| FEEDBACK FORM |
| Health Care Quality Concerns Form |
Your concerns and comments are important to us. If you have concerns about a clinic, doctor or other health care professional, we’d like to hear from you. |
