Documents & Forms
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The forms and materials available on this page are not specific to any particular plan. If you have questions about your plan's coverage, please check your benefit materials, or contact our Customer Service Department.
2021 ID Large Group Master Application (Medical/Dental)
2021 ID Small Group Master Application (Medical/Dental)
2021 MT Large Group Master Application (Medical/Dental)
2021 MT Small Group Master Application (Medical/Dental)
2021 OR Large Group Master Application (Medical/Dental)
2021 OR Small Group Master Application (Medical/Dental)
2021 WA Large Group Master Application (medical)
2021 WA Small Group Master Application (medical)
Accident Report (Medical Service Questionnaire)
Advantage Dental Network Nomination
Attestation of Eligibility
Behavioral Health: Admission Notification Form
Behavioral Health: Preauthorization Request Form
Behavioral Health: Preauthorization Request Form for ABA Services
CHE Budget Form
COBRA Election Form Federal Template (WA)
COBRA Initial Notice Template (WA)
Common Ownership Form
Coordination of Benefits
Corrected Dental Claim Form
Corrected Medical Claim Form
Credentialing - Add a Hospital Based Provider - Provider Information Request Form - MT
Credentialing - Add a Hospital-based Provider - OR WA
Credentialing - Interest Packet for Facilities and Hospitals - OR
Credentialing - Interest Packet for Providers - OR
Credentialing - Recredentialing Application for Providers - OR
Credentialing Application for Facilities and Hospitals - ID
Credentialing Application for Facilities and Hospitals - MT
Credentialing Application for Facilities and Hospitals - OR
Credentialing Application for Providers - ID
Credentialing Application for Providers - MT
Credentialing Application for Providers - OR
Credentialing Application for Providers - WA
Dental Claims Referral Form - Dental Essentials
Designation of Authorized Representative
Electronic Remittance Advice (835) and EFT Authorization Agreement
Employer Exemption Certification for Religious or Moral Objections - WA
First Health Network Nomination
Group Authorization Agreement for Recurring Electronic Fund Transfers (EFT)
Group Coverage Continuation Election Form (WA small group)
Group Identification Form - MT, OR, WA
Health Claim Reimbursement Request Form
Individual Policy Change Form
IPN Network Nomination
Large Group Census - ID (CURV)
Large Group Census - MT
Large Group Request for Quote (census form) - WA
Member Appeal Form
Oregon Request for Confidential Communication
PacificSource, SmartChoice, and SmartHealth Network Provider Nomination
Parent/Guardian Information Form
Prescription Drug Claim Form
Prior Authorization Checklist - Blepharoplasty
Prior Authorization Checklist - Bone Growth (Electronic and Ultrasonic) Stimulators
Prior Authorization Checklist - Instrumented Spinal Surgery
Prior Authorization Checklist - Reduction Mammoplasty
Prior Authorization Checklist - Transcranial Magnetic Stimulation
Prior Authorization Request Form
Prior Authorization/Medication Exception Request Form
Proposal Request: Fully Insured (Large Group 51-99) - WA
Proposal Request: Fully-Insured (Large Group 51-99) - ID
Prospective Agent Appointment Form
Provider Appeal Form
Provider Information Request - MT
Provider Information Request - OR and WA
Provider Offshore Operations Attestation
Quote Request for Small Groups
Renewal Confirmation Form
Request Accounting of Disclosures
Request for Quote Large Group (51+) - MT
Request Record Set Access
Request to Amend a Designated Record Set
RightFit Plan and PCP Selection Form (Washington only)
Short Form Health Statement (required if no claims experience submitted) - MT
Split Carrier Waiver of Coverage
Universal Application (Mid-size Group 51-99) - ID
2021 Value-based Payment Programs
ACA Reporting Requirements Guide
CHE Application Guide
CHE Collaborations 2019-2020
Continuation of Coverage Laws FAQ for Members (Oregon only)
COVID-19 Benefit and Reimbursement Policy FAQ
COVID-19 Provider Relief Plan FAQ
Credentialing Application Rights
Credentialing Criteria
Diagnostic Imaging Prior Authorization List
Drug List - Prior Authorization Criteria
Drug List - Step Therapy Criteria
InTouch for Providers Resource Guide
New and Emerging Technologies: Coverage Status
Pharmacy Network for ID, MT, OR, and WA
Pharmacy Network for ID, MT, OR, and WA (Excel format)
Provider Network Contact List
Provider Peer to Peer FAQ
Recredentialing Criteria
Winning at Wellness Workbook
Provider Manual
2021 ID Individual and Family Brochure
2021 ID Individual and Family Dental Only Plan Comparison
2021 ID Individual and Family Medical Plan Comparison
2021 ID Individual and Family Plan Rates
2021 ID Large Group Brochure
2021 ID Large Group Brochure - Dental Only
2021 ID Small Group Brochure
2021 ID Small Group Dental Only Plan Comparison
2021 ID Small Group Medical Plan Comparison
2021 MT Individual and Family Brochure
2021 MT Individual and Family Dental Only Plan Comparison
2021 MT Individual and Family Medical Plan Comparison
2021 MT Individual and Family Plan Rates
2021 MT Large Group Brochure
2021 MT Large Group Brochure - Dental Only
2021 MT Small Group Brochure
2021 MT Small Group Dental Only Plan Comparison
2021 MT Small Group Medical Plan Comparison
2021 OR Individual and Family Brochure - Navigator & SmartChoice
2021 OR Individual and Family Brochure - Navigator Only - Portland Metro & Central Oregon
2021 OR Individual and Family Dental Only Plan Comparison
2021 OR Individual and Family Medical Plan Comparison
2021 OR Individual and Family Medical Plan Comparison - Navigator Only - Portland Metro & Central Oregon
2021 OR Individual and Family Plan Rates
2021 OR Large Group Brochure
2021 OR Large Group Brochure - Dental Only
2021 OR Small Group Brochure
2021 OR Small Group Dental Only Plan Comparison
2021 OR Small Group Medical Plan Comparison
2021 WA Individual and Family Medical Plan Comparison
2021 WA Individual and Family Plan Rates
2021 WA Large Group Brochure
2021 WA Small Group Brochure
2021 WA Small Group Medical Plan Comparison
Employer Administration Manual
Expanded No-cost Drug List
Large Group ID Self-Funded Dental Flier
Large Group MT Self-Funded Dental Flier
Large Group OR Self-Funded Dental Flier
Medicare Notice A (creditable) Sample Member Notice
Medicare Notice B (noncreditable) Sample Member Notice
Medicare Part D Creditable Coverage FAQ
Medicare Part D Employer Creditability Notice
Medicare Part D ID 2020 Creditability Matrix
Medicare Part D ID 2021 Creditability Matrix
Medicare Part D MT 2020 Creditability Matrix
Medicare Part D MT 2021 Creditability Matrix
Medicare Part D OR 2020 Creditability Matrix
Medicare Part D OR 2021 Creditability Matrix
Medicare Part D WA 2020 Creditability Matrix
Medicare Part D WA 2021 Creditability Matrix
Member Guide (for members with dental-only plans)
Pharmacy Product Guidelines FAQ
Prior Authorization Criteria
Self-Funded Administrative Solutions
Step Therapy Criteria
Value Based Preventive Drug List