Forms & Documents
Information and Guidelines
Ancillary & Additional Products
- Guardian DentalGuard Preferred MAC
- Guardian DentalGuard Preferred PPO 70 UCR
- Guardian DentalGuard Preferred PPO 90 UCR
- Guardian Managed DentalGuard
- Guardian Managed DentalGuard Plus
- Solstice Dental EPO S700B
- Solstice Dental EPO S800B
- Solstice Dental PPO
- Solstice Dental Value PPO MAC
- UnitedHealthcare High PPO MAC
- UnitedHealthcare INO 100/50/50
- UnitedHealthcare Low PPO MAC
- UnitedHealthcare National Exclusive Network
- Guardian Byte
- Guardian DentalGuard Preferred
- Guardian DentalGuard Preferred Plus
- Guardian Managed DentalGuard
- Guardian Managed DentalGuard Plus
- Solstice Dental EPO S700B
- Solstice Dental EPO S800B
- Solstice Dental PPO
- Solstice Dental Value PPO MAC
- UHC INO 10/50/50
- UnitedHealthcare High PPO MAC
- UnitedHealthcare Low PPO MAC
- UnitedHealthcare Select Care DMO
- UnitedHealthcare SmileDirectClub
Enrollment Forms
- Common Law Employee Attestation Form
- Domestic Partner Affidavit
- EE Census Information Template
- Employer EFT/ACH Form
- Group Attestation Form
- HealthPass Small Employer Exception Form
- Member Authorization Form
- New Group COBRA Member/Takeover Form
- Notice of Election Group Application 2024
- Open Enrollment Email Template
Renewal Forms
Summary of Benefits
- Anthem Blue Access Gold EPO 50/55
- Anthem Blue Access Silver EPO 30/75
- Anthem Blue Access Silver EPO HSA 3250
- Anthem Connection Gold EPO 25/50
- Anthem Connection Gold EPO 50/55
- Anthem Connection Platinum EPO 20/40
- Anthem Connection Silver EPO 40/80
- Anthem Platinum EPO 5/25
- Anthem Silver EPO 40/80
- Anthem Silver EPO HSA 4000
- EmblemHealth Select Care Bronze HSA
- EmblemHealth Select Care Bronze Premier
- EmblemHealth Select Care Gold Premier
- EmblemHealth Select Care Platinum Premier
- EmblemHealth Select Care Silver HSA
- EmblemHealth Select Care Silver Premier
- Oxford Liberty Bronze HSA 5750
- Oxford Liberty Gold 30/60 G
- Oxford Liberty Gold EPO 25/50 ZD
- Oxford Liberty Gold EPO 30/60
- Oxford Liberty Gold HSA 1600 M
- Oxford Liberty Platinum EPO
- Oxford Liberty Silver 40/80
- Oxford Liberty Silver EPO 30/60 G
- Oxford Liberty Silver EPO 50/100 ZD
- Oxford Liberty Silver HSA 3000
- Oxford Liberty Silver HSA 4000 M
- Oxford Metro Bronze HSA 7250 G
- Oxford Metro Gold 25/40
- Oxford Metro Gold 25/40 G
- Oxford Metro Silver EPO 30/80 G
- Oxford Metro Silver EPO 50/100 ZD
- Anthem Blue Access Gold EPO 30/55
- Anthem Blue Access Silver EPO 25/50
- Anthem Blue Access Silver EPO HSA 3000
- Anthem Connection Gold EPO 25/50
- Anthem Connection Gold EPO 30/55
- Anthem Connection Platinum EPO 20/40
- Anthem Connection Silver EPO 40/70
- Anthem Platinum EPO 5/25
- Anthem Silver EPO 40/70
- Anthem Silver EPO HSA 3500
- EmblemHealth Prime Bronze HSA
- EmblemHealth Prime Bronze Premier
- EmblemHealth Prime Gold Premier
- EmblemHealth Prime Platinum Premier
- EmblemHealth Prime Silver HSA
- EmblemHealth Prime Silver Premier
- Healthfirst Gold 1350 Pro Plus EPO
- Oxford Liberty Bronze HSA 5750
- Oxford Liberty Gold 30/60 G
- Oxford Liberty Gold EPO 25/50 ZD
- Oxford Liberty Gold EPO 30/60
- Oxford Liberty Gold HSA 1500 M
- Oxford Liberty Platinum EPO
- Oxford Liberty Silver 30/60 G
- Oxford Liberty Silver EPO 40/80
- Oxford Liberty Silver EPO 50/100 ZD
- Oxford Liberty Silver HSA 4000 M
- Oxford Metro Bronze HSA 7000 G
- Oxford Metro Gold 25/40
- Oxford Metro Gold EPO 25/40 G
- Oxford Metro Silver 50/100 ZD
- Oxford Metro Silver EPO 30/80 G
- 2023-0297_Sp_2023_EmblemHealth_Bronze HSA
- 2023-0297_Sp_2023_EmblemHealth_Bronze Premier
- 2023-0297_Sp_2023_EmblemHealth_Gold Premier
- 2023-0297_Sp_2023_EmblemHealth_Platinum Premier
- 2023-0297_Sp_2023_EmblemHealth_Silver HSA
- 2023-0297_Sp_2023_EmblemHealth_Silver Premier
- Anthem Blue Access Gold EPO 30/55
- Anthem Blue Access Silver EPO 25/50
- Anthem Blue Access Silver EPO HSA 3000
- Anthem Connection Gold EPO 25/50
- Anthem Connection Gold EPO 30/55
- Anthem Connection Platinum EPO 20/40
- Anthem Connection Silver EPO 40/70
- Anthem Platinum EPO 5/25
- Anthem Silver EPO 40/70
- Anthem Silver EPO HSA 3000
- Oxford Liberty Bronze HSA 5750
- Oxford Liberty Gold 30/60 G
- Oxford Liberty Gold EPO 25/50 ZD
- Oxford Liberty Gold EPO 30/60
- Oxford Liberty Gold HSA 1500 M
- Oxford Liberty Platinum EPO
- Oxford Liberty Silver 30/60 G
- Oxford Liberty Silver 40/80
- Oxford Liberty Silver EPO 50/100 ZD
- Oxford Liberty Silver HSA 4000 M
- Oxford Metro Bronze HSA 7000 G
- Oxford Metro EPO 25/40
- Oxford Metro EPO 25/40 G
- Oxford Metro Silver EPO 30/80 G
- Oxford Metro Silver EPO 50/100 ZD
ID CARDS
Medical
To view, print or request a new ID Card click on your carrier below. Need Help? Call 888.313.7277 for assistance.
To view and print an ID Card, you need to create an account and register with EmblemHealth. A Member ID number is required for registration.
To view and print an ID Card, you need to create an account and register with Anthem. A Member ID number is required for registration
To view and print your ID Card, you need to create an account and register with UnitedHealthcare. A member ID number and Group/Policy number OR the last 6 digits of the SS# and zip code are required.
DENTAL & VISION
To view, print or request a new ID Card click on your carrier below. Need Help? Call 888.313.7277 for assistance.
To view and print an ID card you, need to create an account and register with Guardian. A member SS# is required for registration.
To view and print your Solstice dental ID Card, you need to create an account and register with Solstice.
- A Member Number or SS# is required for registration.
- Take me to carrier website
To view and print your Solstice vision ID Card:
For those enrolled 6/1/2023 and prior in Davis Vision network plans:
- Create an account register with DavisVision. A Member ID Number, last name and date of birth are required.
- Take me to carrier website
For those enrolled 7/1/2023 and after in a Spectera network plan:
- Create an account register with Mysmile365, a Member ID Number or SS# are required.
- Take me to carrier website
To view and print your ID card, you need to create an account with UnitedHealthcare. A member ID number and Group/Policy number OR last 6 digits of the SS# are required. Sign into myuhcvision.com and choose Account Settings at the top right of the screen. You can request and print new ID cards.