Forms

General CBIA Forms

• Membership Application

For groups with 51-100 employees:

• Enrollment Checklist (updated 11/06)
• Employer Participation Agreement (updated 8/08)
• 2009 HC2 Enrollment/Change form for 51-100 employees (for groups effective or renewing January 2009 and beyond) (updated 10/08)
• 2009 HC Enrollment/Change form for 51-100 employees (for groups renewing January 2009 and beyond) (updated 11/08)
• 2008 HC2 Enrollment/Change form for 51-100 employees (for groups effective or renewing Oct. 2008 through Dec. 2008) (updated 8/08)
• Supply Request Form for 51-100 employees
• Student Verification Form
• Underwriting Request Form 51-100 employees

ConnectiCare

• Mail Order Prescription Form
• Prescription Re-imbursement Claim Form
• Out of Area Medical Claim Form
• Request for Continuation of Coverage for Handicapped Children

Health Net

• Out-of-Network Claims Questionnaire
• Prescription Claim Reimbursement Form
• MHN/HMC Claim Form
• Request for Continuation of Coverage for Handicapped Children
• Disabled Dependent Questionnaire
• Mail Order Prescription Form
• Student Verification Form
• Step Therapy Form

Oxford Health Plans

• Insurance Claim Form
• Medco Health Home Delivery Pharmacy Service Order Form
• Prescription Drug Reimbursement Form
• Consent Form for Release of Confidential Member Information
• Student Verification Form
• General Vision Services
• Deductible Credit Form

Anthem Blue Cross & Blue Shield

• Anthem Enrollment and Membership Change Form (Plan F Medical)
• Blue MedicareRx^SM Prescription Drug Plan Enrollment Form (Medicare Part D)
• Medicare Mail-order Prescription Order Form