Forms & documents
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Enrollment, change of status, & waiver of coverage forms
Oregon small group enrollment forms
2021
- 2021 Total Enhanced, Balance, Standard, HSA, or Integrated HSA plans (PDF)
- 2021 Connect or Choice plans (PDF)
- 2021 Total Enhanced, Balance, Standard, HSA, or Integrated HSA plans – Spanish (PDF)
- 2021 Connect or Choice plans – Spanish (PDF)
2020
- 2020 Total Enhanced, Balance, Standard, HSA, or Integrated HSA plans (PDF)
- 2020 Connect plans (PDF)
- 2020 Total Enhanced, Balance, Standard, HSA, or Integrated HSA plans - Spanish (PDF)
- 2020 Connect plans - Spanish (PDF)
Other Oregon small group forms
Oregon large group enrollment forms
2021
- 2021 Choice, Connect, or HSA Connect plans(PDF)
- 2021 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
- 2021 Choice, Connect, or HSA Connect plans – Spanish (PDF)
- 2021 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans – Spanish (PDF)
2020
- 2020 Choice, HSA, Option Advantage Base, Option Advantage Plus (A), Option Advantage B (Premium), or Integrated HSA plans (PDF)
- 2020 Connect plans (PDF)
- 2020 Choice, HSA, Option Advantage Base, Option Advantage Plus (A), Option Advantage B (Premium), or Integrated HSA plans - Spanish (PDF)
- 2020 Connect plans - Spanish (PDF)
Washington enrollment forms
2021
- 2021 Choice plans (PDF)
- 2021 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
- 2021 Choice plans - Spanish (PDF)
- 2021 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans - Spanish (PDF)
2020
- 2020 Washington plans (PDF)
- 2020 Washington plans - Spanish (PDF)
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Forms for all groups
- Out-of-area dependent enrollment (PDF)
- Transition of care (PDF)
- Other member forms and notices
- Medical home selection form (PDF)
- Enrollment spreadsheet (ZIP)
- Employer reconciliation worksheet (PDF)
- HealthEquity HRA/HSA standard new business notification form
- Implementation checklist - HRA (PDF)
- Implementation checklist - HSA (PDF)
- Implementation checklist - FSA (PDF)
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Continuation of coverage forms
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.
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Health information disclosure forms
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Employer toolkits
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Plan overviews
2021 plan overviews
- Employer groups 1-50 (PDF)
- Employer groups 51+ (PDF)
2020 plan overviews
- Employer groups 1-50 (PDF)
- Employer groups 51+ (PDF)