Forms

General CBIA Forms

• Membership Application (on-line form)
• Membership Application

Health Connections 2 for groups with 3-50 employees:

• CBIA Health Connections Eligibility Guidelines/Enrollment Checklist (3-50 only) (updated 10/08)
• Employer Participation Agreement (updated 8/08)
• Enrollment Statement (updated 9/08)
• 2009 CBIA Health Connections 2 Enrollment/Change Form (for groups effective or renewing January 2009 and beyond) (updated 10/08)
• 2008b CBIA Health Connections 2 Enrollment/Change Form (for groups effective or renewing Oct. 2008 through Dec. 2008) (updated 8/08)
• 2008a CBIA Health Connections 2 Enrollment/Change Form (for groups effective or renewing Jan. 2008 through Sept. 2008) (updated 12/07)
• 2007 CBIA Health Connections 2 Enrollment/Change Form (for groups effective or who last renewed Oct. 2007 through Dec. 2007) (updated 8/07)
• CBIA Health Connections Family Health Statement (updated 11/06)
• Student Verification Form (updated 6/07)
• Waiver Form (updated 3/03)
• CBIA Direct Debit form
• Supply Request Form (updated 11/07)
• Online Supply Request Form

CIGNA Healthcare

• Tel-Drug Mail Order Prescription Form
• Prescription Drug Re-imbursement Form
• Request for Continuation of Coverage for Handicapped Children
• Medical Claim Form
• Authorization for the Disclosure of Private Health Information
• HIPAA Change/Revoke Form
• Guest Privileges brochure

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