Forms and Materials for Washington Employers

The documents on this page were designed to help you manage your group’s coverage. Please contact your Client Service Representative if you have a special request.

Want to promote health and wellness in your organization? Check out our Wellness Communication Toolkit.

Manage Your Group Coverage

2020 Washington Large Group Brochure (medical)  
2020 Washington Small Group Brochure (medical)  
2020 Washington Small Group Medical Plan Comparison  
2020 Small Group Master Application (medical)
Agent of Record Appointment
ERISA: SPD Sample Wrap Template
Group Authorization Agreement for Recurring Electronic Fund Transfers (EFT)
InTouch for Employers - Manage Your Group's Health Plan Benefits Online   
Pharmacy Product Guidelines FAQ

Manage Employee Coverage

Administrative Forms

2020 Large Group Enrollment Application and Waiver of Coverage  
2020 Small Group Enrollment Application and Waiver of Coverage      en Español  
Affidavit of Domestic Partnership  
Nondiscrimination Notice  
RightFit Plan and PCP Selection Form (Washington only)  
Authorization to Use or Disclose PHI en Español
CHIP Notice
Coordination of Benefits Form
Designation of Authorized Representative
Disabled Dependent Certification
Employee Address or Name Change en Español
ERISA: SPD Sample Wrap Template
Request Accounting of Disclosures
Request Record Set Access
Request to Amend a Designated Record Set
Restrict Record Set Access
Termination of Dependent Coverage

Claims and Medical Benefit Forms

Care Coordination Request
Prescription Drug Claim Form

Continuation Coverage Forms

COBRA Initial Notice (Continuation Coverage Rights Under COBRA)
Continuation Election Form (Federal, Word format) en Español
Guide: PacificSource Model Notices

Medicare Part D Notices

Medicare Part D Creditability Matrix (2020)
Medicare Part D Creditable Coverage FAQ
Notice A (creditable) Sample Member Notice en Español
Notice B (noncreditable) Sample Member Notice en Español

Plan Benefits and Information

Medical

Health Insurance: Know the Lingo
How to Submit a Claim
Making Sense of Third Party Recovery en Español
Member Guide en Español
Preauthorization
Provider Directory - Online

Health and Wellness Programs and Information

Health Condition Management Information

Condition Support to Help You Live Well en Español
Global Emergency Services Tri-fold Brochure
Member Guide en Español
Understanding and Overcoming Depression

Wellness Programs

Jenny Craig
Prenatal Program en Español
Weight Watchers Program en Español

Online Tools

InTouch for Employers - Manage Your Group's Health Plan Benefits Online
Provider Directory - Online

Payroll Inserts

24-Hour NurseLine

 

InTouch for Members

Last updated 1/13/2020