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
Enrollment Forms
- COBRA Takeover Form
- Common Law Employee Attestation Form
- Domestic Partner Affidavit
- EE Census Information Template
- Employer EFT/ACH Form
- Group Attestation Form
- HealthPass Small Employer Exception Form
- Medical Waiver Form
- Member Authorization Form
- Notice of Election Group Application 2025
- Open Enrollment Email Template
Renewal Forms
Summary of Benefits
- Anthem Blue Access Gold EPO 30/65 G
- Anthem Blue Access Gold EPO 50/60
- Anthem Blue Access Silver 35/75
- Anthem Blue Access Silver EPO 40/80 G
- Anthem Blue Access Silver EPO HSA 3300
- Anthem Connection Gold 25/50
- Anthem Connection Gold 50/60
- Anthem Connection Gold EPO 30/65 G
- Anthem Connection Platinum EPO 20/40
- Anthem Connection Silver 40/80
- Anthem Connection Silver 40/80 G
- Anthem Gold EPO 30/65 G
- Anthem Platinum EPO 5/25
- Anthem Silver EPO 40/80
- Anthem Silver EPO 40/80 G
- Anthem Silver EPO HSA 4100
- Oxford Freedom Gold HSA 1650
- Oxford Freedom Platinum EPO
- Oxford Liberty Bronze HSA 5750
- Oxford Liberty Gold EPO 25/50 ZD
- Oxford Liberty Gold EPO 30/60/1250
- Oxford Liberty Gold EPO 30/60/1800
- Oxford Liberty Silver EPO 30/60
- Oxford Liberty Silver EPO 40/80
- Oxford Liberty Silver EPO 50/100 ZD
- Oxford Liberty Silver HSA 4000 PR
- Oxford Metro Bronze HSA 7250 G
- Oxford Metro EPO Gold 25/40 G
- Oxford Metro Gold EPO 25/40
- Oxford Metro Silver EPO 30/80
- Oxford Metro Silver EPO 50/100 ZD
- UnitedHealthcare Choice Gold 40/60 DY-LQ
- UnitedHealthcare Choice Gold EPO 15/100 DY-MD
- UnitedHealthcare Choice Gold EPO 15/30 DY-LK
- UnitedHealthcare Choice Gold EPO 30/60 DY-LV
- UnitedHealthcare Choice Gold EPO 40/70 DY-LS
- UnitedHealthcare Choice Gold HSA 1800 DY-LM PR
- UnitedHealthcare Choice Platinum 15/25 DY-LR
- UnitedHealthcare Choice Platinum EPO 10/25 DY-LJ
- UnitedHealthcare Choice Platinum EPO 10/80 DY-MB
- UnitedHealthcare Choice Silver EPO 15/100 DY-MF
- UnitedHealthcare Choice Silver EPO 30/75 DY-LL
- UnitedHealthcare Choice Silver HSA 2750 DY-L7
- UnitedHealthcare Choice Silver HSA 3200 DY-LN PR
- 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
- Oxford Liberty Silver 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 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 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
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.
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.