Forms and Applications

Advanced Directives

Agent of Record Form

Authorizations for Release of Medical Information

Broker Appointments

Broker Sign In

Coordination of Benefits

Electronic Commission Payments/Reports

Enrollment Applications

BusinessEDGE®

Enrollment Applications Small Group 1-50

Only use these files for 1-50 plans (new hires, renewals)

    Enrollment Applications Mid-Market 51-150 Eligible

    Employer Group Enrollment Applications (Small Group and Mid Market)

    Enrollment Applications (Large Group)

    HIPAA Agreement for PHI

    Member Appeals Forms

    Out-of-Area Dependent Child Forms

    Pharmacy Mail Order Forms

    Pharmacy Reimbursement Form

    Student Verification Forms

    Transitional Care Forms

    The American Recovery and Reinvestment Act of 2009 Forms

    Sell Optima Health Plans

    Access sales resources to help you sell plans for employer groups, OptimaFit Individual & Family Plans, or Medicare plans.

    Brokers