Forms
Administrative Forms
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Affidavit of Domestic Partnership - Group
Legally establish a domestic partnership for the purposes of enrolling your partner on your health insurance plan.
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Direct Bill COBRA Paperwork
COBRA and New York Continuation of Benefits billing.
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Disability Certification Form
Certification of an unmarried child's disability and eligibility for continued coverage.
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Student Dependent Verification Form
This form must be completed to verify that your dependent age 19 or over is a full-time student at an accredited college or university.
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Termination Request Form
All subscriber terminations must be written on this form to be processed properly.
HIPAA Authorization Forms - Employers
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How to Complete Plan Sponsor Certifications of Group Health Plan HIPAA
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HIPAA Form 2(I) Plan Sponsor Certification of Group Health Plan HIPAA Compliance and Authorization for Third Party Access to PHI
Completion of this form confirms Plan Sponsor’s compliance with applicable HIPAA requirements and identifies third parties authorized to receive PHI on behalf of the Plan Sponsor.
Large Group & Small Group Enrollment Application/Change Forms