Broker Resources

• Aetna NY New Business Case Submission Checklist ^{(14.03.947.1-NY E (3/12)}
• Aetna NY Small Group Employer Application ^{(GR-96241-NY (10/10) R-POD M) 2012}
• Aetna NY Small Group Employee Enrollment/Change Form ^{(GR-67834-16 (10/10) NY-SGB R-PODL ) 2012}
• Addendum to New Business Input Documents Information Needed to Support Required Medical LossRatio Reporting under Health Care Reform Law^{GR-68720 (1-13) 2013}
• Employer Verification Form^{(EI930 (6/10) ) & (EI930B (6/10) ) 2012}
• Proof of Eligibility Form  ^{(05/19/06) 2012}
• Associated Companies Form ^{(9/9/09) 2012}
• Aetna Late Paperwork Submission Form  ^{(GR-68702 (2-11) ) 2012}
• Aetna NY Employer Funding Certification and Statement of Understanding for Small Employers ^{(14.32.902.1-NY (5/10) ) 2012}
• Aetna Joinder Agreement  ^{(GR-67987 (4-04) R-POD ) 2012}
• Aetna Declaration of Domestic Partnership ²⁰¹²
• Aetna NYC Community Plan Guide²⁰¹²
  
• Aetna NY Provider Network Brochure^{14.03.152.1-NY (9/09) 2012}
• Aetna NYCCP Individual PCP List²⁰¹²
• Aetna Savings Plus Member Flyer ²⁰¹³
• Complete Kit²⁰¹³

• Aetna NJ New Business Case Submission Checklist ^{(14.03.947.1-NJ A (4/11) ) 2012}
• Aetna NJ Addendum to New Business Input Documents Mandatory Requirement for Health Care Reform ^{(GR-68720 (7-11) ) 2012}
• Aetna NJ Application for a Small Group Health Benefits Policy^{GR-96241-NJ (4-12) V2 R-POD M}
• Aetna NJ Employer Certification^{(GR-68099 (1-11) R-POD A) 2012}
• Aetna NJ Small Group Enrollment/Change Request ^{(GR-67834-27 (4-12) V2 R-POD M}
• Aetna NJ Small Employer Health Benefits Waiver of Coverage  ^{(GR-67618 (5-05) R-POD) 2012}
• Aetna NJ Proof of Eligibility Form^{(6/25/04) 2012}
• Aetna NJ HSA Declaration of Understanding ^{(41.03.102.1-NJ (2/06) ) 2012}
• Aetna NJ Small Employer Funding Certification and Statement of Understanding Attestation Form  ^{(14.32.902.1-NJ A (2/10) ) 2012}
• Aetna NJ Associated Companies  (9/9/09) 2012
• Aetna NJ Small Group Underwriting PEO (Professonal Employer Organization)/Leased Employees^{(GR-68509 (1-09) ) 2012}
• Aetna NJ Request for Participation and Joinder Agreement^{(GR-67987 (4-04) R-POD) 2012}
• Aetna NJ New Business Late Submission Form ^{(GR-68702 (2-11) ) 2012}
• Complete Kit ²⁰¹³

• Aetna CT New Business Case Submission Checklist  ^{(14.03.947.1-CT E (4/11) ) 2012}
• Aetna Addendum to New Business Input Documents Mandatory Requirement for Health Care Reform ^{(GR-68720 (7-11) 2012}
• Aetna Employer Information Form ^{(EI930 (6-10) & (EI930B (6-10) 2012}
• Aetna CT Small Group Business Employee Enrollment/Change Form ^{(GR-67834-24 (7/11) CT – SGB R-POD I) 2012}
• Aetna CT Small Group Business Employer Application  ^{(GR-96241-CT (7-11) R-POD M) 2012}
• Aetna Small Employer Health Benefits Waiver of Coverage  ^{(14.09.302.1-CT) 2012}
• Aetna Family Health Statement  ^{(GR-68102-1 (4-05) CT-SGB R-POD) 2012}
• Aetna Associated Companies^{(9/9/09) 2012}
• Aetna Request for Participation and Joinder Agreement  ^{(GR-67987 (4-04) R-POD) 2012}
• Aetna New Business Late Submission Form  ^{(GR-68702 (2-11) ) 2012}
• Complete Kit ²⁰¹²

• Aetna Health Equity HSA Welcome/How to Enroll ^{(14.36.901.1) 2012}
• Aetna Health Equity HSA Brochure^{(GC0N07-01) 2012}
• Aetna SBS Brochure ^{(64.10.300.1-NY A (7/11) ) 2012}
• Aetna HealthFund HSA Employer Enrollment Form   ^{(Aetna_Employer_HSA_200911) 2012}
• Aetna HealthFund HSA Employee Enrollment Form  ^{(Aetna HealthFund HSA Employee Enrollment Form _200912) 2012}
• Aetna HealthFund HSA Beneficiary Designation Form  ^{(Aetna Health Fund HSA Benificiary Designation Form _20101029) 2012}
• Aetna Health Equity HSA Custodial Agreement  ^{(HEQ HSA CUSTODIAL AGREEMENT 20110616) 2012}
• Aetna HealthFund HSA Rollover/Transfer Request Form  ^{(Aetna_HSA_Transfer_Rollover Form_200911) 2012}
• Aetna NY Employer Funding Certification and Statement of Understanding for Small Group  ^{(14.32.902.1-NY (5/10) 2012}
• Aetna NJ Small Employer Funding Certification and Statement of Understanding Attestation Form  ^{(14.32.902.1-NJ A (2/10) 2012}
• Aetna CT Employer/Broker Funding Certification for Small Group Plans with In-Network Deductible  ^{(14.32.902.1-CT B (12/10) 2012}
• Aetna HSA Fee Schedule ^{(01/11 F10) 2012}
• Complete Kit ²⁰¹³

• AmeriHealth Account Installation Checklist ^{(4/08) 2012}
• AmeriHealth Application for Small Employer Health Benefits Policy ^{(20130827) – 2013}
• AmeriHealth Employee Enrollment/Change Application ^{(ahenchga.pm65) 2012}
• AmeriHealth Enrollment/Change Request ^{(01412 05/07) 2012}
• AmeriHealth Dependent to Age 31 Enrollment Application²⁰¹²
• AmeriHealth Employer Authorization Letter for EFT of Initial Premium²⁰¹²
• AmeriHealth Plan Change Letter²⁰¹² 
• How to Sell AmeriHealth Underwriting and Administrative Guidelines^{(10/16/2008) 2012}
• AmeriHealth Small Employer Health Benefits Waiver of Coverage ^{(6761 12/03) 2012} 
• AmeriHealth New Jersey Small Employer Certification ^{(AHNJ SEH Cert rev. 4/13/11) 2012}
• AmeriHealth Declaration of Understanding (PPO)²⁰¹²
• AmeriHealth Declaration of Understanding (EPO) ²⁰¹²   
• Complete Kit^2013/14

• Easy Choice Case Installation Form^{(ECHPNY-00115 S&M Revised 12/09) 2012}
• Easy Choice Producer Compensation Disclosure Statement^{(COMP 14.0 Producer Compensation Transparency) 2012}
  Required With ALL New Business Case Submissions
• Easy Choice Group Agreement Form^{(AHP-00087 Rev01092011) 2012}
• Easy Choice Notice of Enrollment Period And Waiver Form^{(AHP-00116 Revised 4/08) 2012}
• Easy Choice Previous Insurance Coverage Form ^{(AHP-00121 Revised 04/08) 2012}
• Easy Choice Employee Enrollment Form ^{(AHP-00085 EmployeeEnrollmentForm v3.) 2013}
• Easy Choice Credit Card/Debit Card Payment Authorization ^{(AHP-00062 B&E Credit/ACH Form) 2012}
• Easy Choice Declaration of Domestic Partnership & Declaration of Termination of Domestic Partnership ²⁰¹²
• Complete Kit ^{(6/27/12) 2012}

• Emblem Health Small Group Underwriting Guidelines ^5/2013
• Emblem Health Letter of Certification
• Emblem Health Small Employer Group Master Application ^{(155-23-EMHMOAPP 09/11)2012}
• Emblem Health Transaction Form for Group Accounts ^{(16-1613 12/11)}
• Emblem Health Small Group Waiver
• Emblem Health Student Verification Form
• Emblem Health Claim Form
• Emblem Health Domestic Partner Enrollment Policy
• Complete Kit

• Emblem Health HSA Small Employer Group Application
• Emblem Health HSA Letter of Certification
• Emblem Health HSA Transaction Form for Group Health²⁰¹²
• Emblem Health Student Verification Form
• Emblem Health HSA Application
• Emblem Health HSA Employer Set-up form
• Emblem Health HSA Contribution Work Sheet
• Emblem Health/HIP Network Comparison
• Complete Kit

• HealthPass Eligilibility Guidelines ^{(v1of1 10.12) 2013}
• HealthPass CheatSheet 3Q ²⁰¹³
• HealthPass Enrollment Checklist^{(HPS-020v1 of 1 10.12) 2013}
• HealthPass Notice of Election ^{(HPSv2o2 4.13) 2013}
• HealthPass Enrollment/Change Form ^{(HPS-v2of2 7.13) 2013}
  
• HealthPass EmblemHealth Health Essentials SOB^(4.13)
• HealthPass Letter of Certification²⁰¹²
• HealthPass Electronic Funds Transfer Form ^{(V2of2 10.12) 2012}
• HealthPass Network Availability ^{(HPS-018 v3 of3 10.12) 2013}
• HealthPass Pharmacy Options ^{(HPS-019v1of1 10.12) 2012}
• HealthPass Declaration of Cohabitation^{(HPS-60 V1 of 1 7.01.12) 2012}
• HealthPass Health Advocate ²⁰¹³
• Complete Kit 3Q ²⁰¹³

• Healthy NY Application for Small  Business ²⁰¹³

• HIP Underwriting Guidelines 7/1/10
• HIP New Business Underwriting Checklist
• HIP Subscriber Member Enrollment Form
• HIP Group Application
• HIP Refusal of Insurance
• HIP Prime Small Group Application
• HIP Change/Term Transmittal Sheet
• HIP Select EPO Small Group Option Sheet
• HIP Prime EPO Small Group Option Sheet
• HIP Prime PPO Small Group Option Sheet
• HIP Prime POS Small Group Option Sheet
• HIP Access I Small Group Option Sheet
• HIP Access II Small Group Option Sheet
• HIP Classic Small Group Option Sheet
• HIP Domestic Partner Coverage Details
• Complete Kit

• Horizon Application for Small Group Health Benefits

Below you will find the forms that must be completed and submitted for each New Jersey small
employer group applying for standard health insurance coverage:

•      Small Employer Group Application Instructions ^{(7215 (W0611)}
•      Horizon BCBS of NJ Group Enrollment/Change Request ^{(6803 (W08/11) ) 2012}
•      Application For A Small Group Health Benefits Policy ^{(2535 (W0611)}
•      New Jersey Small Employer Certification ^{(2466 (W0411)}
•      Small Employer Health Benefits Waiver of Coverage ^{(2465 (W0311)}

• Horizon BCBS of NJ Group Enrollment/Change Request ^{(6803 (W08/11) ) 2012}
• Horizon BCBS of NJ Employment Verification Form For Groups Two To Five Eligible – ^{This form is to be used only for a brand new company 5116 (W0604) ) 2012}
• Horizon BCBS of NJ Confirmation of HSA Funding^{(5890 (W0811)  2013}
• Horizon BCBS of NJ Declaration of Understanding²⁰¹²
• Horizon Late Paperwork Form
• Horizon Dependent To Age 30 Enrollment Form Template
• Horizon Declaration of Understanding²⁰¹²
• Confirmation of HSA Selection ²⁰¹³
• Mellon Doc EB Form²⁰¹²
• New Discovery Doc²⁰¹²
• Horizon NJ Complete Kit²⁰¹³

Miscellaneous Forms

• Horizon Conversion Form

• LIA Employer Agreement^(5/2012)
• LIA Employer Renewal Agreement^(5/2012)
• LIA New Business Required Documentation Checklist^(5/2012)
• LIA Enrollment/Change Application ^(5/2012)
• LIA Enrollment Form Renewal^(5/2012)
• LIA Electronic Debit Form^(5/2012)
• LIA Broker Registration^(5/2012)
• LIA Easy Choice Previous Insurance Coverage^(5/2012)
• LIA Emblem Small Group Benefits Waiver form ^(5/2012)
• Complete Kit 2012
  

Oxford 2013 PDL – Traditional

Oxford 2013 PDL –  Advantage

Oxford NY Small Group (1-50) Underwriting Guidelines 2013/14

Participation & Underwriting Guidelines Update New York (NY) & New Jersey (NJ) Renewing Small Groups (2-50) 2013

Oxford NY Underwriting Guidelines 51-99

Oxford Direct Deposit Form 2013/14

Oxford NY (Freedom Plan)

• New York Community-Rated Small Group Application ^{OHPNY HMO GA S 2014 10173 R7}
• Group Affirmation Letter ^{(NY-00-776) 2012}
• New York Member Enrollment Form – OHP ^{(OHPNY MEF LS 1109 333 REV 10) 2014}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R 5) 2012}
• New York Health Benefits Waiver of Coverage  ^{(OHINY Waiver LS 711 3313 Rev 6) 2014}
• Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
• Complete Kit ²⁰¹²

• New York Community-Rated Small Group Application ^{OHPNY HMO GA S 2014 10173 R7}
• Group Affirmation Letter ^{(NY-00-776) 2012}
• New York Member Enrollment Form – OHP ^{(OHPNY MEF LS 1109 333 REV 10) 2014}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R 5) 2012}
• New York Health Benefits Waiver of Coverage ^{(OHINY Waiver LS 711 3313 Rev 6) 2014}
• Add/Term/Change Form^{(MS 07-422 003 REV 8) 2012}
• Complete Kit ²⁰¹²

• NY Small Group Application – (OHI) ^{OHI NY GA S 2014 R36}
• Group Affirmation Letter ^{(NY-00-776) 2012}
• New York Member Enrollment Form – OHI ^{(OHINY MEF LS 1109 4318 REV 8) 2014}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}
• New York Health Benefits Waiver of Coverage ^{(OHINY Waiver LS 711 3313 Rev 6) 2014}
• Add/Term/Change Form^{(MS 07-422 003 REV 8) 2012}
• Complete Kit ²⁰¹³
  

• NY Small Group Application – (OHI) ^{OHI NY GA S 2014 R36}
• Group Affirmation Letter ^{(NY-00-776) 2012}
• New York Member Enrollment Form – OHI ^{(OHINY MEF LS 1109 4318 REV 8) 2014}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}
• New York Health Benefits Waiver of Coverage ^{(OHINY Waiver LS 711 3313 Rev 6) 2014}
  
• Add/Term/Change Form^{(MS 07-422 003 REV 8) 2012}
• Complete Kit ²⁰¹³

• New York Community-Rated Small Group Application ^{OHPNY HMO GA S 2014 10173 R7}
• Group Affirmation Letter ^{(NY-00-776) 2012}
• New York Member Enrollment Form – OHP^{(OHPNY MEF LS 1109 333 REV 10) 2014}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}
• New York Health Benefits Waiver of Coverage ^{(OHINY Waiver LS 711 3313 Rev 6) 2014}
• Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
• Complete Kit ²⁰¹²

• New York Community-Rated Small Group Application ^{OHPNY HMO GA S 2014 10173 R7}
• Group Affirmation Letter ^{(NY-00-776) 2012}
• New York Member Enrollment Form – OHP^{(OHPNY MEF LS 1109 333 REV 10) 2014}
• Dental Enrollment Form ^{(OHP DE 10/96  040 Rev 5) 2012}
• New York Health Benefits Waiver of Coverage ^{(OHINY Waiver LS 711  3313 Rev 6) 2014}
• Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
• Complete Kit ²⁰¹²

• NY Small Group Application – (OHI) ^{OHI NY GA S 2014 R36}
• Group Affirmation Letter ^{(NY-00-776) 2012}
• New York Member Enrollment Form – OHI ^{(OHINY MEF LS 1109 4318 REV 8) 2014}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev 5) 2012}
• New York Health Benefits Waiver of Coverage ^{(OHINY Waiver LS 711 3313 Rev 6) 2014}
• Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
• Complete Kit ²⁰¹³

• NY Small Group Application – (OHI) ^{OHI NY GA S 2014 R36}
• Group Affirmation Letter ^{(NY-00-776) 2012}
• New York Member Enrollment Form – OHI ^{(OHINY MEF LS 1109 4318 REV 8) 2014}
• Dental Enrollment Form ^{(OHP DE 10/96  040 Rev 5) 2012}
• New York Health Benefits Waiver of Coverage ^{(OHINY Waiver LS 711  3313 Rev 6) 2014}
• Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
• Complete Kit ²⁰¹³

• NY Liberty HMO Small Group Application ^{(OHPNY GA HMO 811 10173 R5) 2012}
• Group Affirmation Letter ^{(NY-00-776) 2012}
• New York Member Enrollment Form – OHP^{(OHPNY MEF LS 1109 333 REV 10) 2014}
• New York Health Benefits Waiver of Coverage ^{(OHINY Waiver LS 711  3313 Rev 6) 2014}
• Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
• Complete Kit ²⁰¹²

• NY Small Group Application – (OHI) ^{OHI NY GA S 2014 R36}
• Group Affirmation Letter ^{(NY-00-776) 2012}
• New York Member Enrollment Form – OHI ^{(OHINY MEF LS 1109 4318 REV 8) 2014}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}
• New York Health Benefits Waiver of Coverage ^{(OHINY Waiver LS 711  3313 Rev 6) 2013}
• Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
• Complete Kit ²⁰¹³

GROUP

• NY Small Group Application – (OHI) ^{(OHINY GA S 811 4228 R32) 2013}
• HSA Employer Set-Up Bank Notification ^{(06-327 7423 R4) 2012}

MEMBER

• Account Holder Brochure ^{(045-0136 9/04) 2012}
• HSA Card Agreement – OptumHealth Bank ^{(12/07 OH-FSV-DM-21208-993) 2012}
• HSA Privacy Notice – OptumHealth Bank ^{(045-0132 11/07) 2012}
• HSA Custodial and Deposit Agreement – OptumHealth Bank ^{(045-0131 11/07) 2012}
• HSA Application – OptumHealth Bank ^{(045-0130 11/07) 2012}
• Complete Kit ²⁰¹³

• Healthy New York Small Employer Group Application ^{(OHPNY GA HNY S 1111 4526 R18) 2012}
• Healthy New York Application for Individuals and Sole Proprietors ^{(OHP NY GA HNY ISP 1111 4529 R20) 2012}
• Healthy New York Group Enrollment Agreement ^{(OHPNY HNY GEA 605) 2012}
• New York Member Enrollment Form – OHP^{(OHPNY MEF LS 1109 333 REV 10) 2014}
• Healthy New York Re-certification for Small Employers ^{(OHP NY Recert HNY S 1111 6473 R14) 2012}
• Healthy New York Re-certification for Individuals and Sole Proprietors ^{(OHP NY Recert HNY ISP 1109 6472 R11) 2012}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}
• New York Health Benefits Waiver of Coverage ^{(OHINY Waiver LS 711 3313 Rev 6) 2014}
• Complete Kit ²⁰¹²

• Member Enrollment Form ^{(OHINY MEFLS 1109 4318 REV8) 2012}
• New York Small Group Oxford USA Addendum ^{(OHINY GA S OXUSA 307 4789 Rev 21) 2012}
• New York Health Benefits Waiver of Coverage ^{(OHINY Waiver LS 711 3313 Rev 6) 2014}
• Complete Kit ²⁰¹²

Oxford NJ Underwriting Guidelines

Oxford NJ (Freedom Plan)

• Application for a Small Employer Health Benefits Policy OHI – ^{(OHINJ GA S 2014 1 1087 R22) 2014}
• NJ Small Member Enrollment/Change Request Form – OHI^{(OHI NJ S MEF 7/04 6856 R7) 2012}
• NJ Small Employer Health Benefits Waiver of Coverage ^{(OHI NJ SEH WC 1086 R5)2012}
• NJ Small Employer Certification ^{(SEH-SEC-6/94-1 NJ-11-018 1089 R4) 2012}
• Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}
• Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form^{(OHPNJ MEF LS HINT SUPP 406 #8831 R1}
• Complete Kit ²⁰¹³

• Application for a Small Employer Health Benefits Policy OHI –^{(OHINJ GA S 2014 1 1087 R22) 2014}
• NJ Small Member Enrollment/Change Request Form – ^{OHI (OHI NJ S MEF 7/04 6856 R7) 2012}
• NJ Small Employer Health Benefits Waiver of Coverage ^{(OHI NJ SEH WC 1086 R5) 2012}
• NJ Small Employer Certification^{(SEH-SEC-6/94-1 NJ-11-018 1089 R4) 2012}
• Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5)2012}
• Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form ^{(OHPNJ MEF LS HINT SUPP 406 #8831R1) 2012}
• Complete Kit ²⁰¹³

• Application for a Small Employer Health Benefits Policy OHI – ^{(OHINJ GA S 2014 1 1087 R22) 2014}
• NJ Small Member Enrollment/Change Request Form – OHI ^{(OHI NJ S MEF 7/04 6856 R7) 2012}
• NJ Small Employer Health Benefits Waiver of Coverage ^{(OHI NJ SEH WC 1086 R5) 2012}
• NJ Small Employer Certification ^{(SEH-SEC-6/94-1 NJ-11-018 1089 R4) 2012}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}
• Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form ^{(OHPNJ MEF LS HINT SUPP 406 #8831R1) 2012}
• Complete Kit ²⁰¹³

• Application for a Small Employer Health Benefits Policy OHI – ^{(OHINJ GA S 2014 1 1087 R22) 2014}
• NJ Small Member Enrollment/Change Request Form – OHI (OHI NJ S MEF 7/04 6856 R7) 2012
• NJ Small Employer Health Benefits Waiver of Coverage ^{(OHI NJ SEH WC 1086 R5) 2012}
• NJ Small Employer Certification ^{(SEH-SEC-6/94-1 NJ-11-018 1089 R4) 2012}
• Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}
• Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form^{(OHPNJ MEF LS HINT SUPP 406 #8831R1) 2012}
• Complete Kit ²⁰¹³

• Application for a Small Employer Health Benefits Policy OHI –^{(OHINJ GA S 2014 1 1087 R22) 2014}
• NJ Small Employer Health Benefits Waiver of Coverage ^{(OHI NJ SEH WC 1086 R5) 2012}
• NJ Small Employer Certification ^{(SEH-SEC-6/94-1 NJ-11-018 1089 R4) 2012}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}
• Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form ^{(OHPNJ MEF LS HINT SUPP 406 #8831R1) 2012}
• Complete Kit ²⁰¹³

• Application for a Small Employer Health Benefits Policy OHI – ^{(OHINJ GA S 2014 1 1087 R22) 2014}
• NJ Small Member Enrollment/Change Request Form – OHI ^{(OHI NJ S MEF 7/04 6856 R7)2012}
• NJ Small Employer Health Benefits Waiver of Coverage ^{(OHI NJ SEH WC 1086 R5) 2012}
• NJ Small Employer Certification^{(SEH-SEC-6/94-1 NJ-11-018 1089 R4) 2012}
• Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}
• Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form ^{(OHPNJ MEF LS HINT SUPP 406 #8831R1) 2012}
• Complete Kit ²⁰¹³

• Small Group Application – OHP ^{(OHPNJ GA S 2014 7026 R19) 2014}
• NJ Small Member Enrollment/Change Request Form – OHP ^{(OHI NJ S MEF 7/04 6855 R7) 2012}
• NJ Small Employer Health Benefits Waiver of Coverage ^{(OHI NJ SEH WC 1086 R5) 2012}
• NJ Small Employer Certification ^{(SEH-SEC-6/94-1 NJ-11-018 1089 R4) 2012}
• NJ Small Group Attachment A – OHP ^{(NJ-10-895 6836 R6) 2012}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}
• Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form ^{(OHPNJ MEF LS HINT SUPP 406 #8831R1) 2012}
• Complete Kit ²⁰¹²

• New Jersey Small Group Oxford USA Addendum^{(NJ-07-606 4787 Rev17) 2012}
• Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form ^{(OHPNJ MEF LS HINT SUPP 406 #8831R1) 2012}
• Complete Kit ²⁰¹²

GROUP

• New Jersey Large Group Application – OHI ^{(OHI LG GR APP 708 4744 Rev 17) 2012}
• HSA Bank Notification Form ^{(06-327 7423 R4) 2012}
• New Jersey Certificate of Understanding – Small Group ^{(OHI NJ DOU DRCT HSA S 2068766-Small Group) 2012}
•  Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form ^{(OHPNJ MEF LS HINT SUPP 406 #8831R1) 2012}

MEMBER

• Account Holder Brochure ^{(045-0136 9/04) 2012}
• HSA Card Agreement – OptumHealth Bank ^{(12/07 OH-FSV-DM-21208-993) 2012}
• HSA Privacy Notice – OptumHealth Bank^{(045-0132 11/07) 2012}
• HSA Custodial and Deposit Agreement – OptumHealth Bank ^{(045-0131 11/07) 2012}
• HSA Application – OptumHealth Bank ^{(045-0130 11/07) 2012}
•  Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form ^{(OHPNJ MEF LS HINT SUPP 406 #8831R1) 2012}

• Application for a Small Employer Health Benefits Policy – OHI^{(OHI NJ SM APP 5/04 1087 R18) 2012}
• New Jersey Small Member Enrollment/Change Request Form – OHI ^{(OHI NJ S MEF 7/04 6856 R7) 2012}
• New Jersey Small Employer Health Benefits Waiver of Coverage ^{(OHI NJ SEH WC 1086 R5) 2012}
• Oxford MyPlan Health Reserve Account Group Application (Not Available – Visit oxhp.com)
• Oxford MyPlan Check Drafting Authorization (Not Available – Visit oxhp.com)
• Oxford MyPlan Claim Disbursement ACH Authorization Release (Not Available – Visit oxhp.com)
• Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form ^{(OH PNJ MEF LS HINT SUPP 406 #8831 R1) 2012} 
• Complete Kit ²⁰¹²

Oxford CT Underwriting Guidlines

• Connecticut Small Group Application ^{(OHPCT GA S 3111768 R15) 2012}
• Connecticut Small Group Attachment A – OHP^{(OHPCT UG S 5/04 5806 Rev6) 2012}
• Member Enrollment and Physician Selection Form^{(CT-10-255 4207 R9) 2012}
• Connecticut Health Benefits Waiver of Coverage^{(CT-03-756 6424 R5) 2012}
• Connecticut Family Health Statement^{(CT-11-0038 6357 R5)}
• Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}
• CT Premium Payments for Termed Employees^{(CT-09-608) 2012}
• Employer Request for Premium Credit Form ^{(CT-10-541) 2012}
• Complete Kit ²⁰¹²

• Connecticut Small Group Application ^{(OHPCT GA S 3111768 R15) 2012} 
• Connecticut Small Group Attachment A – OHP ^{(OHPCT UG S 5/04 5806 Rev6) 2012}
• Member Enrollment and Physician Selection Form ^{(CT-10-255 4207 R9) 2012}
• Connecticut Health Benefits Waiver of Coverage^{(CT-03-756 6424 R5) 2012}
• Connecticut Family Health Statement^{(CT-11-0038 6357 R5) 2012}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}
• CT Premium Payments for Termed Employees^{(CT-09-608) 2012}
• Employer Request for Premium Credit Form ^{(CT-10-541) 2012}
• Complete Kit ²⁰¹²

• Connecticut Small Group Application – OHI ^{(OHICT GA S 311 5121 R17) 2012} 
• Connecticut Member Enrollment Form – OHI ^{(CT-10-254 5123 Rev9) 2012}
• Connecticut Health Benefits Waiver of Coverage ^{(CT-03-756 6424 R5) 2012}
• Connecticut Family Health Statement ^{(CT-11-0038 6357 R5) 2012}
• Connecticut Small Group Attachment A-OHI ^{(OHICT UG S 5/04 5798 Rev6) 2012}
• CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}
• Employer Request for Premium Credit Form ^{(CT-10-541) 2012}
• Complete Kit ²⁰¹²

• Connecticut Small Group Application ^{(OHPCT GA S 3111768 R15) 2012} 
• Connecticut Small Group Attachment A – OHP ^{(OHPCT UG S 5/04 5806 Rev6) 2012}
• Member Enrollment and Physician Selection Form ^{(CT-10-255 4207 R9) 2012}
• Connecticut Health Benefits Waiver of Coverage^{(CT-03-756 6424 R5) 2012}
• Connecticut Family Health Statement^{(CT-11-0038 6357 R5) 2012}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}
• CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}
• Employer Request for Premium Credit Form^{(CT-10-541) 2012}
• Complete Kit ²⁰¹²

• Connecticut Small Group Application^{(OHPCT GA S 3111768 R15) 2012} 
• Connecticut Small Group Attachment A – OHP^{(OHPCT UG S 5/04 5806 Rev6) 2012}
• Member Enrollment and Physician Selection Form ^{(CT-10-255 4207 R9) 2012}
• Connecticut Health Benefits Waiver of Coverage^{(CT-03-756 6424 R5) 2012}
• Connecticut Family Health Statement^{(CT-11-0038 6357 R5) 2012}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}
• CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}
• Employer Request for Premium Credit Form^{(CT-10-541) 2012}
• Complete Kit ²⁰¹²

• Connecticut Small Group Application^{(OHPCT GA S 3111768 R15) 2012} 
• Connecticut Small Group Attachment A – OHP ^{(OHPCT UG S 5/04 5806 Rev6) 2012}
• Member Enrollment and Physician Selection Form^{(CT-10-255 4207 R9) 2012}
• Connecticut Health Benefits Waiver of Coverage^{(CT-03-756 6424 R5) 2012}
• Connecticut Family Health Statement ^{(CT-11-0038 6357 R5) 2012}
• Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}
• CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}
•  Employer Request for Premium Credit Form ^{(CT-10-541) 2012}
• Complete Kit ²⁰¹²

• Connecticut Small Group Application^{(OHPCT GA S 3111768 R15) 2012}
• Connecticut Small Group Attachment A – OHP ^{(OHPCT UG S 5/04 5806 Rev6) 2012}
• Member Enrollment and Physician Selection Form^{(CT-10-255 4207 R9) 2012}
• Connecticut Health Benefits Waiver of Coverage^{(CT-03-756 6424 R5) 2012}
• Connecticut Family Health Statement^{(CT-11-0038 6357 R5) 2012}
• Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}
• CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}
• Employer Request for Premium Credit Form ^{(CT-10-541) 2012}
• Complete Kit ²⁰¹²

• Connecticut Small Group Application^{(OHPCT GA S 3111768 R15) 2012}
• Connecticut Small Group Attachment A – OHP^{(OHPCT UG S 5/04 5806 Rev6) 2012}
• Member Enrollment and Physician Selection Form^{(CT-10-255 4207 R9) 2012}
• Connecticut Health Benefits Waiver of Coverage^{(CT-03-756 6424 R5) 2012}
• Connecticut Family Health Statement ^{(CT-11-0038 6357 R5) 2012}
• Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}
• CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}
• Employer Request for Premium Credit Form^{(CT-10-541) 2012}
• Complete Kit ²⁰¹²

• Connecticut Small Group Application ^{(OHPCT GA S 3111768 R15) 2012}
• Connecticut Small Group Attachment A – OHP^{(OHPCT UG S 5/04 5806 Rev6) 2012}
• Member Enrollment and Physician Selection Form ^{(CT-10-255 4207 R9) 2012}
• Connecticut Health Benefits Waiver of Coverage ^{(CT-03-756 6424 R5) 2012}
• Connecticut Family Health Statement^{(CT-11-0038 6357 R5) 2012}
• Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}
• CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}
• Employer Request for Premium Credit Form^{(CT-10-541) 2012}
• Complete Kit ²⁰¹²

• Connecticut Small Group Application – OHI ^{(OHICT GA S 311 5121 R17) 2012} 
• Connecticut Member Enrollment Form – OHI ^{(CT-10-254 5123 Rev9) 2012}
• Connecticut Health Benefits Waiver of Coverage ^{(CT-03-756 6424 R5) 2012}
• Connecticut Family Health Statement^{(CT-11-0038 6357 R5) 2012}
• Oxford MyPlan Health Reserve Account Group Application (Not Available – Visit oxhp.com)
• Oxford MyPlan Check Drafting Authorization (Not Available – Visit oxhp.com)
• Oxford MyPlan Claim Disbursement ACH Authorization Release (Not Available – Visit oxhp.com)
• CT Premium Payments for Termed Employees^{(CT-09-608) 2012}
• Employer Request for Premium Credit Form^{(CT-10-541) 2012}
• Complete Kit ²⁰¹²

• Connecticut Small Group Blue Ribbon Application ^{(OHICT GA BR S 508 4556 R6) 2012} 
• Connecticut Small Group Attachment A – OHP ^{(OHPCT UG S 5/04 5806 Rev6) 2012}
• CT Premium Payments for Termed Employees^{(CT-09-608) 2012}
• Employer Request for Premium Credit Form ^{(CT-10-541) 2012}
• Complete Kit ²⁰¹²

GROUP

• Connecticut Large Group Application-OHI ^{(OHICT GA L 508 07/11 5122 R19)}
• HSA Bank Notification Form^{(06-327 7423 R4)2012}

MEMBER

• Account Holder Brochure^{(045-0136 9/04) 2012}
• HSA Card Agreement – OptumHealth Bank ^{(12/07 OH-FSV-DM-21208-993) 2012}
• HSA Privacy Notice – OptumHealth Bank^{(045-0132 11/07) 2012}
• HSA Custodial and Deposit Agreement – OptumHealth Bank ^{(045-0131 11/07) 2012}
• HSA Application – OptumHealth Bank ^{(045-0130 11/07) 2012}
• CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}
• Employer Request for Premium Credit Form^{(CT-10-541) 2012}

• Connecticut Small Group Application (1768) (in-area employees) ^{(OHPCT GA S 311 1768 R15) 2012}
• Connecticut Small Group Application – OHI (5121) (out-of-area employees) ^{(OHICT GA S 311 5121 R17) 2012}
• Member Enrollment and Physician Selection Form (in-area employees) ^{(CT-10-255 4207 R9) 2012}
• Connecticut Member Enrollment Form – OHI (out-of-area employees) ^{(CT-10-254 5123 Rev9) 2012}
• CT Premium Payments for Termed Employees ^{(CT-09-608)2012}
• Employer Request for Premium Credit Form ^{(CT-10-541) 2012}
• Complete Kit ²⁰¹²

Oxford Large Group 2014 NY Plan Portfolio

Oxford Large Group 2014 NJ Plan Portfolio

 United Healthcare -Large Group

• Request for Quote ²⁰¹²