Forms & documents

Enrollment, change of status, & waiver of coverage forms
Oregon small group enrollment forms

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)
2021
Other Oregon small group forms
- 2021 Oregon standardized group size determination form (PDF)
- SHOP Participation Request form (PDF)
Oregon large group enrollment forms

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)
2021
Washington enrollment forms

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)
2021
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)
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.
Health information disclosure forms
Employer toolkits
- Groups sized 50+ Health Coaching Toolkit (PDF)
- Groups sized 50+ Primary Care Provider Toolkit (PDF)
Plan overviews
2022 plan overviews
- Employer groups 1-50 (PDF)
- Employer groups 51+ (PDF)
2021 plan overviews
- Employer groups 1-50 (PDF)
- Employer groups 51+ (PDF)