2020 forms

To view, fill out and print the forms on this page, you will need the latest version of Adobe Acrobat Reader, which can be downloaded. However, Adobe Acrobat Reader does not allow you to save your completed, or partially completed, forms to a disk or on your computer. For that expanded capability you will need to have the complete Adobe Acrobat software package, version 5.0 or later.

Enrollment/change of status/waiver of coverage forms

Oregon small groups

Choose your small group plan: 

Oregon large groups

Choose your large group plan:

Washington plans

  • 2020 Washington plans (PDF coming soon)
  • 2020 Washington plans – Spanish (PDF coming soon)

Forms for all groups

  • Out-of-area dependent enrollment (PDF)
  • Transition of care (PDF)
  • Other member forms and notices
  • Medical home selection form (PDF)
  • Enrollment spreadsheet (ZIP)
  • Employer reconciliation worksheet (PDF)
  • HealthEquity HRA/HSA standard new business notification form (PDF)

Oregon small-group forms

  • 2020 Oregon standardized group size determination form (PDF)

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.

Health information disclosure forms for all groups