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.

• Commission payment direct deposit form (PDF)

Enrollment/change of status/waiver of coverage forms

Oregon small groups

Choose your small group plan: 

• 2020 Total Enhanced, Balance, Standard, HSA, or Integrated HSA plans (PDF)
• 2020 Connect plans (PDF)
• 2020 Total Enhanced, Balance, Standard, HSA, or Integrated HSA plans – Spanish (PDF)
• 2020 Connect plans – Spanish (PDF)

Oregon large groups

Choose your large group plan:

• 2020 Choice, HSA, Option Advantage Base, Option Advantage Plus (A), Option Advantage B (Premium), or Integrated HSA plans (PDF)
• 2020 Connect plans (PDF)
• 2020 Choice, HSA, Option Advantage Base, Option Advantage Plus (A), Option Advantage B (Premium), or Integrated HSA plans – Spanish (PDF)
• 2020 Connect plans – Spanish (PDF)

Washington plans

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

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)
• HealthEquity HRA/HSA standard new business notification form (PDF)

Oregon small-group forms

• 2020 small group Statewide enrollment kit
  (For use when Connect is not purchased). Packaged together in a single PDF, the Statewide enrollment kit contains all the forms you’ll need for Oregon small group enrollment: the master contract application, Oregon group size determination (GSD) form, enrollment/change of status/waiver form, and underwriting guidelines.
• 2020 small group Connect enrollment kit
  Packaged together in a single PDF, the Connect enrollment kit contains all the forms you’ll need for Oregon small group enrollment: the master contract application, Oregon group size determination (GSD) form, Connect enrollment/change of status/waiver form, medical home selection form and underwriting guidelines.
• 2020 master contract application (PDF)
• 2020 producer checklist for small group enrollment (PDF)
• 2020 small group underwriting guidelines (PDF)
• 2020 Oregon standardized group size determination form (PDF)
• SHOP Participation Request Form (PDF)

View 2019 forms ›

Change forms for individual and family insurance plans

2020 Oregon plans

• 2020 online Special Enrollment change form for individual and family insurance (PDF)
• 2020 fillable change form for individual and family insurance (PDF)
  (Use if your client needs to list more than four dependents.)

2019 Oregon plans

The Special Enrollment Period for 2019 is closed.

The only qualifying events left for 2019 coverage are birth, adoption, placement for adoption, foster care of a child or a court order. Use the link below to access the online and paper change forms to make changes applicable to these qualifying events.

• 2019 online change form for individual and family insurance
• 2019 fillable change form for individual and family insurance (PDF)
  (Use if your client needs to list more than three dependents.)

2020 Washington plans

For changes to current 2020 coverage, visit WaHealthPlanFinder.org.

• 2020 fillable change form for Individual and family insurance PDF)

Enrollment forms for individual and family plans

2020 plans

• Fillable application for Oregon individual and family insurance (PDF)
• Fillable application for Washington individual and family insurance (PDF)

Medicare forms

• Appointment for agent of record (PDF)
• Scope of appointment (PDF)
• Producer home visit checklist (PDF)
• Medicare plan rating (PDF)

Secret shopper surveillance tools

• Consolidated secret shopping tool (PDF)
• Private individual marketing appointment secret shopping tool (PDF)
• Public event secret shopping tool (PDF)

Health information disclosure forms for all groups

• Requesting access to one's health plan records
• Changing and restricting access to one's health plan records
• Request for Confidential Communications
• Allowing others to share one's protected health information