Forms & documents

Oregon small group enrollment forms

2025

• 2025 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans (PDF)
• 2025 Connect or Choice plans (PDF)
• 2025 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans – Spanish (PDF)
• 2025 Connect or Choice plans – Spanish (PDF)

2024

• 2024 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans (PDF)
• 2024 Connect or Choice plans (PDF)
• 2024 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans – Spanish (PDF)
• 2024 Connect or Choice plans – Spanish (PDF)

Other Oregon small group forms

• 2025 Oregon group size determination form (PDF)
• 2024 Oregon group size determination form (PDF)
• SHOP Participation Request form (PDF)

Oregon large group enrollment forms

2025

• 2025 Choice, Connect or HSA Connect plans (PDF)
• 2025 Option Advantage, HSA, or Personal Option plans (PDF)
• 2025 Choice, Connect, or HSA Connect plans – Spanish (PDF)
• 2025 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans – Spanish (PDF)

2024

• 2024 Choice, Connect or HSA Connect plans (PDF)
• 2024 Option Advantage, HSA, or Personal Option plans (PDF)
• 2024 Choice, Connect, or HSA Connect plans – Spanish (PDF)
• 2024 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans – Spanish (PDF)

Washington enrollment forms

2025

• 2025 Choice plans (PDF)
• 2025 Choice plans - Spanish (PDF)
• 2025 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
• 2025 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans - Spanish (PDF)

2024

• 2024 Choice plans (PDF)
• 2024 Choice plans - Spanish (PDF)
• 2024 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
• 2024 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans - Spanish (PDF)

• Out-of-area dependent enrollment (PDF)
• Transition of care (PDF)
• Other member forms and notices
• Medical home selection form (PDF)
• Medical home selection form - Spanish (PDF)
• Enrollment spreadsheet (ZIP)
• Employer reconciliation worksheet (PDF)
• HealthEquity standard new business form 
• Implementation checklist - HRA (PDF)
• Implementation checklist - HSA (PDF)
• Implementation checklist - FSA (PDF)

Vision claim form

• VSP reimbursement form (PDF)
  (Use when services are rendered by a non-VSP provider)
• Vision claim form (PDF)
  (Use if you have a Vision $200, Vision $300 or Vision $400 plan administered by Providence Health Plan)

Termed members may be eligible for continued coverage. The following resources will help administrators determine continuation of coverage eligibility and steps to take to continue coverage.

• Continuation of coverage (COBRA, state continuation of coverage, portability plans) (PDF)
• State continuation election form - English (PDF)
• State continuation election form - Spanish (PDF)
• COBRA continuation election form - English (PDF)
• COBRA continuation election form - Spanish (PDF)

• Requesting access to one's health plan records (PDF)
• Changing and restricting access to one's health plan records (PDF)
• Request for Confidential Communications - Oregon (PDF)
• Request for Confidential Communications - Washington (PDF)
• Allowing others to share one's protected health information(PDF)

• Groups sized 50+ Health Coaching Toolkit (PDF)
• Groups sized 50+ Primary Care Provider Toolkit (PDF)

2025 plan overviews

• Employer groups 1-50 (PDF)
• Employer groups 51+ (PDF)

2024 plan overviews

• Employer groups 1-50 (PDF)
• Employer groups 51+ (PDF)

The group size questionnaire is used to determine if Medicare pays primary or secondary to your group health plan coverage. It is also used to determine continuation of coverage.

 

• Annual group size questionnaire (PDF)