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.
2020 ID Group Master Application (Medical/Dental)
2020 MT Group Master Application (Medical/Dental)
2020 OR Group Master Application (Medical/Dental)
2020 WA Large Group Enrollment Application and Waiver of Coverage
2020 WA Large Group Master Application (medical)
2020 WA Small Group Master Application (medical)
Accident Report (Medical Service Questionnaire)
Advantage Dental Network Nomination
Behavioral Health: Admission Notification Form
Behavioral Health: Preauthorization Request Form
Behavioral Health: Preauthorization Request Form for ABA Services
Care Coordination Request Form
CHE Budget Form
COBRA Election Form Federal Template (WA)
COBRA Initial Notice Template (WA)
Common Ownership Form
CPAP-BiPap Rent to Purchase Request
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
Designation of Authorized Representative
Electronic Remittance Advice (835) and EFT Authorization Agreement
Employer Exemption Certification for Religious or Moral Objections
First Health Network Nomination
Group Authorization Agreement for Recurring Electronic Fund Transfers (EFT)
Group Coverage Continuation Election Form (WA small group)
Group Identification Form
Health Claim Reimbursement Request Form
ID Universal Application (Mid-size Group 51-99)
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
Preauthorization Checklist - Blepharoplasty
Preauthorization Checklist - Bone Growth Stimulator Electrical and Electromagnetic
Preauthorization Checklist - Bone Growth Stimulator Ultrasonic
Preauthorization Checklist - CPAP Replacement
Preauthorization Checklist - Dental as Medical
Preauthorization Checklist - Facility Fee - Pediatric Dental Under Medical Outpatient
Preauthorization Checklist - Implanted Spinal Stimulator
Preauthorization Checklist - Implanted Spinal Stimulator Trial
Preauthorization Checklist - Instrumented Spinal Surgery
Preauthorization Checklist - Oral Appliance for Obstructive Sleep Apnea
Preauthorization Checklist - Reduction Mammoplasty
Preauthorization Checklist - Transcranial Magnetic Stimulation (rTMS) Checklist
Preauthorization Request Form
Preauthorization/Medication Exception Request Form
Prescription Drug Claim Form
Prospective Agent Appointment Form
Provider Appeal Form
Provider Information Request - MT
Quote Request for Small Groups
Renewal Confirmation Form
Request Accounting of Disclosures
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)
Split Carrier Waiver of Coverage
Washington Proposal Request: Fully Insured (Large Group 51-99)
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
Covid19 Diagnostic (Viral)Testing and Antibody (Serology) Testing
Credentialing Application Rights
Credentialing Criteria
Diagnostic Imaging Preauthorization List
Drug List - Preauthorization Policies
Drug List - Step Therapy Policies
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
Recredentialing Criteria
Provider Manual
2020 ID Individual and Family Brochure
2020 ID Individual and Family Dental Only Plan Comparison
2020 ID Individual and Family Medical Plan Comparison
2020 ID Individual and Family Plan Rates
2020 ID Large Group Brochure
2020 ID Large Group Brochure - Dental Only
2020 ID Sample Limitations and Exclusions (Medical)
2020 ID Small Group Brochure
2020 ID Small Group Dental Only Plan Comparison
2020 ID Small Group Medical Plan Comparison
2020 MT Individual and Family Brochure
2020 MT Individual and Family Brochure - Dental Only
2020 MT Individual and Family Medical Plan Comparison
2020 MT Individual and Family Plan Rates
2020 MT Large Group Brochure
2020 MT Large Group Brochure - Dental Only
2020 MT Small Group Brochure
2020 MT Small Group Dental Only Plan Comparison
2020 MT Small Group Medical Plan Comparison
2020 OR Individual and Family Brochure
2020 OR Individual and Family Brochure (Navigator only)
2020 OR Individual and Family Dental Only Plan Comparison
2020 OR Individual and Family Medical Plan Comparison
2020 OR Individual and Family Medical Plan Comparison (Navigator only)
2020 OR Individual and Family Plan Rates
2020 OR Large Group Brochure
2020 OR Large Group Brochure (Dental Only)
2020 OR Small Group Brochure
2020 OR Small Group Dental Only Plan Comparison
2020 OR Small Group Medical Plan Comparison
2020 WA Individual and Family Plan Comparison
2020 WA Large Group Brochure
2020 WA Small Group Brochure
2020 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 2020 Creditability Matrix
Member Guide (for members with dental-only plans)
Pharmacy Product Guidelines FAQ
Self-Funded Administrative Solutions