Forms and Applications

Advanced Directives

• My Advance Care Plan (Form)
• My Advance Care Planning Guide

Agent of Record Form

• Agent of Record - Change Request

Authorizations for Release of Medical Information

• Disabled Dependent Certification Form
• Designated Representative Authorization Form
• Formulario para la autorización de un representante designado
• Authorization for Use or Disclosure of Medical Information - THIS FORM MUST BE USED BY HEALTH EQUITY MEMBERS ONLY
• Authorization for Use or Disclosure of Medical Information (Designated Agent)
• Revocation of Authorization Form
• Personal Health Information (PHI) Restriction Form

Broker Appointments

• Broker Appointment Form

Broker Sign In

• Confidentiality Agreement and Portal User Profile Form

Coordination of Benefits

• Coordination of Benefits form

Electronic Commission Payments/Reports

• Electronic Payment/Remittance Enrollment Form

Enrollment Applications

• 2023 OptimaFit^® Individual Health Coverage (OHP)
• Optima Equity Health Savings Account (HSA) Enrollment Form

BusinessEDGE^®

• BusinessEDGE® Employee Enrollment Application (Height and Weight must be included for both underwriting and applying for coverage)
• BusinessEDGE® Group Auto Debit Withdrawal Form
• BusinessEDGE® Employer Application
• BusinessEDGE® Medical Risk Form/High Risk & High Cost Conditions List

Enrollment Applications Small Group 1-50

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

• 2023 Small Group 1-50 Member Enrollment Application

Enrollment Applications Mid-Market 51-150 Eligible

• 2023 Mid-Market 51-150 Member Enrollment Application
• 2023 Employee Health Questionnaire Application

Employer Group Enrollment Applications (Small Group and Mid Market)

• 2023 Employer Small Group Application
• Virginia Group Health Insurance Medical History Form
• Optima Equity Health Savings Account (HSA) Enrollment Form
• Employer Group Health Questionnaire
• Enrollment Spreadsheet
• 1099 Eligibility and Attestation Form

Enrollment Applications (Large Group)

• 2023 Combined Large Group Member Enrollment Application
• Self Funded Member Enrollment Application
• Enrollment Spreadsheet

HIPAA Agreement for PHI

• HIPAA Agreement

Member Appeals Forms

• Member Appeals Packet
• Member Complaints Packet
• Member Complaints Packet (Family Care Members)

Out-of-Area Dependent Child Forms

• Out-of-Area Dependent Child Form — for members enrolled in the Out-of-Area Dependent Program
• Out-of-Area Dependent Child Form — for members whose employer has purchased the Out-of-Area dependent rider

Pharmacy Mail Order Forms

• Mail Order Form
• Mail Order Frequently Asked Questions
• Mirena Eligibility Form
• Mirena Order Form
• Sentara Home Infusion Pharmacy Request Form For Injectables
• Specialty Pharmacy FAQs (Briova)
• BriovaRx Request Form for Injectables
• Specialty Pharmacy FAQs (Proprium Pharmacy)

Pharmacy Reimbursement Form

• Direct Member Reimbursement Form
• Instructions for Pharmacy Reimbursement

Student Verification Forms

• Student Verification Form

Transitional Care Forms

• Transitional Care Request Form

The American Recovery and Reinvestment Act of 2009 Forms

• Virginia Small Employer COBRA
• COBRA 35% Letter
• Optima Health ARRA Form