Forms

These commonly requested forms are provided to assist you with new group applications and renewals, as well as the services you provide to our mutual customers during the year.

Group forms

•	Checklist for New Groups — HMO
•	Checklist for New Groups — HMO/ PPO
•	Group Administration Manual
•	Master Application — Large Group HMO
•	Master Application — Small Group HMO
•	Master Application — Small Group HMO/ PPO
•	Employer Health Questionnaire (25+ employees)
•	Request for Quote
•	Sole Proprietor, Partner, or Corporate Officer Statement

Member forms

•	Continuity of Care
•	Declination of Coverage — HMO
•	Declination of Coverage — Small Group PPO
•	Designation of Personal Representative
•	Domestic Partnership Declaration
•	Employee Application — Large Group HMO
•	Employee Application — Small Group HMO
•	Employee Application — Small Group PPO
•	Employee Application — Spanish
•	Member Reimbursement Form — Medical Services
•	Member Reimbursement Form — Prescription Drugs
•	PHI Release Form — English
•	PHI Release Form — Spanish

Order materials

The form provided below can be used to request marketing, enrollment and benefit materials.

•	Materials Request Form

We’re here to help

For general inquiries, please use our Contact Us Form.

If you need immediate assistance, please don’t hesitate to pick up the phone and call. We are available Monday through Friday, 8 am to 5 pm.

•	For information about quotes, rates or materials: (619) 228-2429
•	For information about member-specific issues: (619) 228-2300 or 1-800-359-2002

You will need Adobe Acrobat Reader to view and download these files.

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Forms