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Health Insurance Resource Center - Forms
Health Insurance Resource Center
AMERIHEALTH
Claims
HIPAA Authorization for Disclosure of Health Info
Dental Claim Form
Out of Pocket Maximum Reimbursement Form
Davis Vision Reimbursement Claim Form
Individual
2018 AmeriHealth Individual Application
ACH Credit Debit Card Form
Large Group
Large Group Certification
Pharmacy
Future Scripts Rx Reimbursement Form 2-50
Small Group
2015 Small Group Waiver
2018 Small Group Account Installation Broker Checklist
2016 Small Group Dental Application
2018 SEH new business kit
2018 Small Group Master Application
AmeriHealth HSA Acclaris Group Application
AmeriHealth HSA Acclaris Transfer Decline Form
AmeriHealth HSA PNC Group Application
Electronic Withdrawl of Initial Payment Letter
POS Claim Form
Prior Carrier Deductible Credit
Large Group Enrollment Form
Large Group Underwriting Guidelines
Future Scripts Rx Mail Order Form 2-50
PPO Claim Form
Small Group Employer Certification
DU31 Application
Large Group Change Form
Portal Access Form
Small Group Member Application
Future Scripts Rx Prior Authorization Form
Guest Advantage Application
Small Group Waiver of Coverage
Handicap Child Claim Form
Copay Reimbursement Form
Plan Change Form
Future Scripts Rx Reimbursement Form 51+
Declaration of Understanding
2018 Enrollment Change Request Form
2018 AmeriHealth Master Application
CIGNA
Medical/Dental/Vision Enrollment/Change Form
Mutual of Omaha NJ Medicare Supplement Application
Mutual of Omaha MD Medicare Supplement Application
DELTA DENTAL
Group Master Application
Small Group Master Application
2017 Enrollment/Change Form
New Jersey Forms
HORIZON
Claims
Request To Represent a Deceased Member
Deductible Carry Over Credit Report
Individual
2018 Horizon Individual Application
2017 Non-Group Enrollment/Change Request - NEW!
2017 Individual Termination Form
Away from Home Care Services Application
2017 Individual Conversion Form
2017 Dental and Vision Non-Group Enrollment/Change Request
Large Group
51+ Request for Continuation of Enrollment for a Disabled Dependent
51+ Employee Application
Small Group
2017 Small Group Enrollment/ Change Request
Spanish Version: Special Enrollment Documentation Requirements
English Version: Special Enrollment Documentation Requirements
2017 Small Employer Certification
2017 Small Employer Waiver
Auto Pay Application
2-5 Form
Away From Home Care Services Application
Conversion Request Form
HSA Funding Form
Mellon Paperwork
Declaration of Understanding
Small Employer Common Ownership Certification
Spanish Version: New Group Application
Spanish Version: Waiver of Coverage
Spanish Version: Enrollment Change Form
Horizon Health Plus Plan Application
Highlighted Small Group New Business Paperwork
Horizon Large Group Certification 2018
2018 SEH New Business Kit
2018 SHOP New Business Kit
SEP & Documentation for Health Plans Purchased Off-Exchange
Highlighted Small Group Enrollment/Change Request
HORIZON ANCILLARY
Small Employer Vision Group Application
Small Employer Dental Group Application
Horizon Health Plus Plan with Medical Application
Horizon Dental Waiver
Spending and Savings Account Forms
METLIFE
Enrollment Change Form
Statement of Responsibility
NJ Master Application
Metlife Binder Check Cover Form
Metlife NJ DHMO App
eCensus Format
Group Submission Application
Group Submission Disclosure Form
OSCAR
Individual
2018 IHC Application
Small Group
2018 Small Group Enrollment Eligibility Checklist
2018 Small Employer EFT Form
2018 Small Employer Master Application
2018 Small Employer Enrollment Change Form
2018 Small Group New Business Kit
2018 Small Employer Certification
2018 Small Employer Waiver
OXFORD
Claims
Health Insurance Claim Form
HIPAA Member Authorization
Exercise Facility Reimbursement Form
Authorization for Broker to Act as Benefits Administrator
Prescription Drug Reimbursement Claim Form
Pharmacy
OptumRx Authorization Form
Small Group
2017 Small Employer Certification
2017 Small Employer Group Application
2018 Oxford OHP Small Group Application
2018 Oxford OHI Small Group Application
Disability Questionnaire
Oxford Direct Debit Authorization form
NJ Small Group Forms
General Forms
Oxford Verification Form
Oxford New York Small Group Application and Annual Certification Form
NJ Small Group Tax Requirement Instruction Sheet
Common Ownership Form for Affiliated Groups
Sweat Equity Program Reimbursement Form
OXFORD ANCILLARY
NEW- OBM Master Application rev. 9/2018
UHC Dental & Vision Enrollment Application
OBM Small Group Checklist
UHC Dental & Vision Master Application
OBM dental/vision employee application
QUALCARE
2018 New Business Paperwork
2018 Transitional Care Form
2018 Enrollment Form
2018 Employee Waiver of Coverage
2018 Employer Certification
2018 Employer Plan Selection Form
2018 Participation Request/Contract
2018 Disable Dependent Form
Underwriting Tips &Tricks
List of new business requirements
USABLE
USAble Census Template
Employee Enrollment Form
Small Group New Case Submission Materials
USAble Change Form
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