Oregon small group enrollment forms

2023

• 2023 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans (PDF)
• 2023 Connect or Choice plans (PDF)
• 2023 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans – Spanish (PDF)
• 2023 Connect or Choice plans – Spanish (PDF)

2022

• 2022 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans (PDF)
• 2022 Connect or Choice plans (PDF)
• 2022 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans – Spanish (PDF)
• 2022 Connect or Choice plans – Spanish (PDF)

Other Oregon small group forms

• 2023 Oregon standardized group size determination form (PDF)
• SHOP Participation Request form (PDF)

Oregon large group enrollment forms

2023

• 2023 Choice, Connect or HSA Connect plans (PDF)
• 2023 Option Advantage, HSA, or Personal Option plans (PDF)
• 2023 Choice, Connect, or HSA Connect plans – Spanish (PDF)
• 2023 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans – Spanish (PDF)

2022

• 2022 Choice, Connect, or HSA Connect plans (PDF)
• 2022 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
• 2022 Choice, Connect, or HSA Connect plans – Spanish (PDF)
• 2022 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans – Spanish (PDF)

Washington enrollment forms

2023

• 2023 Choice plans (PDF)
• 2023 Choice plans - Spanish (PDF)
• 2023 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
• 2023 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans - Spanish (PDF)

2022

• 2022 Choice plans (PDF)
• 2022 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
• 2022 Choice plans - Spanish (PDF)
• 2022 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 HRA/HSA standard new business notification form 
• Implementation checklist - HRA (PDF)
• Implementation checklist - HSA (PDF)
• Implementation checklist - FSA (PDF)

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 (PDF)
• COBRA continuation election form (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)

2023 plan overviews

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

2022 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)