Forms & documents
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Enrollment, change of status, & waiver of coverage forms
Oregon small group enrollment forms
2024
- 2024 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans (PDF)
- 2024 Connect or Choice plans (PDF)
- 2024 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans – Spanish (PDF)
- 2024 Connect or Choice plans – Spanish (PDF)
2023
- 2023 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans (PDF)
- 2023 Connect or Choice plans (PDF)
- 2023 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans – Spanish (PDF)
- 2023 Connect or Choice plans – Spanish (PDF)
Other Oregon small group forms
- 2024 Oregon standardized group size determination form (PDF)
- 2023 Oregon standardized group size determination form (PDF)
- SHOP Participation Request form (PDF)
Oregon large group enrollment forms
2024
- 2024 Choice, Connect or HSA Connect plans (PDF)
- 2024 Option Advantage, HSA, or Personal Option plans (PDF)
- 2024 Choice, Connect, or HSA Connect plans – Spanish (PDF)
- 2024 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans – Spanish (PDF)
2023
- 2023 Choice, Connect or HSA Connect plans (PDF)
- 2023 Option Advantage, HSA, or Personal Option plans (PDF)
- 2023 Choice, Connect, or HSA Connect plans – Spanish (PDF)
- 2023 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans – Spanish (PDF)
Washington enrollment forms
2024
- 2024 Choice plans (PDF)
- 2024 Choice plans - Spanish (PDF)
- 2024 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
- 2024 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans - Spanish (PDF)
2023
- 2023 Choice plans (PDF)
- 2023 Choice plans - Spanish (PDF)
- 2023 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
- 2023 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans - Spanish (PDF)
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Forms for all groups
- Out-of-area dependent enrollment (PDF)
- Transition of care (PDF)
- Other member forms and notices
- Medical home selection form (PDF)
- Medical home selection form - Spanish (PDF)
- Enrollment spreadsheet (ZIP)
- Employer reconciliation worksheet (PDF)
- HealthEquity standard new business form
- Implementation checklist - HRA (PDF)
- Implementation checklist - HSA (PDF)
- Implementation checklist - FSA (PDF)
Vision claim form
- VSP reimbursement form (PDF)
(Use when services are rendered by a non-VSP provider) - Vision claim form (PDF)
(Use if you have a Vision $200, Vision $300 or Vision $400 plan administered by Providence Health Plan)
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Continuation of coverage forms
Termed members may be eligible for continued coverage. The following resources will help administrators determine continuation of coverage eligibility and steps to take to continue coverage.
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Health information disclosure forms
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Employer toolkits
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Plan overviews
2024 plan overviews
- Employer groups 1-50 (PDF)
- Employer groups 51+ (PDF)
2023 plan overviews
- Employer groups 1-50 (PDF)
- Employer groups 51+ (PDF)
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Group size questionnaire
The group size questionnaire is used to determine if Medicare pays primary or secondary to your group health plan coverage. It is also used to determine continuation of coverage.