Forms & Documents
Information and Guidelines
GENERAL INFORMATION
ENROLLMENT AND NETWORK INFORMATION
ANCILLARY AND ADDITIONAL PRODUCTS AND SERVICES
- Allstate Identity Protection
- Beyond Med
- COBRA Administration
- Guardian AccidentGuard Adv
- Guardian Byte
- Guardian DentalGuard Preferred
- Guardian DentalGuard Preferred Plus
- Guardian EverGuard
- Guardian EverGuard Plus
- Guardian Managed DentalGuard
- Guardian Managed DentalGuard Plus
- Guardian VisionGuard
- Health Advocate
- LifeLock ID Theft
- Nationwide Pet Insurance
- OCA - FSA & Commuter Benefits
- Pet Plan
- Section 125 POP Kit
- Solstice Dental EPO S700B
- Solstice Dental EPO S800B
- Solstice Dental PPO
- Solstice Dental Value PPO MAC
- Solstice Vision 5 PPO July - December 2023
- Solstice Vision PPO January - June 2023
- UnitedHealthcare High PPO MAC
- UnitedHealthcare INO 100/50/50
- UnitedHealthcare Low PPO MAC
- UnitedHealthcare Select Care DMO
- UnitedHealthcare SmileDirectClub
- UnitedHealthcare Vision
REIMBURSEMENT FORMS
CARRIER PRESCRIPTION LISTS
Webinars
AGENT/BROKER CREDENTIALING
Enrollment Forms
Enrollment Change Forms 2022
ENROLLMENT CHANGE FORMS 2023
ENROLLMENT MATERIALS
- Common Law Employee Attestation Form
- Domestic Partner Affidavit
- EE Census Information Template
- Employer - EFT/ACH Form
- EverGuard Conversion Form
- Group Attestation Form
- HealthPass Small Employer Exception Form
- Member Authorization Form
- New Group COBRA Member/Takeover Form
- Notice of Election Group Application 1/1/2023 - 2/1/2023
- Notice of Election Group Application 3/1/2023
- Notice of Election Group Application 4/1/2023
- Notice of Election Group Application 5/1/2023
- Notice of Election Group Application 6/1/2023
- Notice of Election Group Application 7/1/2023 - 12/1/2023
- Open Enrollment Email Template
Renewal Forms
RENEWALS
- HealthPass Online Portal (HOP) Renewal Guide
- Renewal Attestation Form
- Renewal Forms & Documents 4/1/2023
- Renewal Forms & Documents 7/1/2023 - 12/1/2023
- Renewal Forms & Documents First Quarter 2023
- Renewal Forms and Documents 5/1/2023
- Renewal Forms and Documents 6/1/2023
- Renewal Group Mapping 1/1/2023 - 4/1/2023
- Renewal Group Mapping 4th Quarter 2022
- Renewal Group Mapping 5/1/2023
- Renewal Group Mapping 6/1/2023
- Renewal Group Mapping 7/1/2023 - 12/1/2023
- Renewal Group Mapping 7/1/2023 - 12/1/2023
Summary of Benefits
2023 SUMMARY OF BENEFITS AND COVERAGE (SBC)
- EmblemHealth Prime Bronze HSA
- EmblemHealth Prime Bronze Premier
- EmblemHealth Prime Gold Premier
- EmblemHealth Prime Platinum Premier
- EmblemHealth Prime Silver HSA
- EmblemHealth Prime Silver Premier
- Empire Blue Access Gold EPO 30/55
- Empire Blue Access Silver EPO 25/50
- Empire Blue Access Silver EPO HSA 3000
- Empire Connection Gold EPO 25/50
- Empire Connection Gold EPO 30/55
- Empire Connection Platinum EPO 20/40
- Empire Connection Silver EPO 40/70
- Empire Platinum EPO 5/25
- Empire Silver EPO 40/70
- Empire Silver EPO HSA 3500
- 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 RESUMEN DE LA COBERTURA DE BENEFICIO (SBC)
- Empire Blue Access Gold EPO 30/55
- Empire Blue Access Silver EPO 25/50
- Empire Blue Access Silver EPO HSA 3000
- Empire Connection Gold EPO 25/50
- Empire Connection Gold EPO 30/55
- Empire Connection Platinum EPO 20/40
- Empire Connection Silver EPO 40/70
- Empire Platinum EPO 5/25
- Empire Silver EPO 40/70
- Empire 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
2022 SUMMARY OF BENEFITS AND COVERAGE (SBC)
- EmblemHealth Bridge Gold PPO
- EmblemHealth Bridge Gold Virtual
- EmblemHealth Bridge Platinum PPO
- EmblemHealth Milennium Bronze Premier G
- EmblemHealth Milennium Bronze Value G
- EmblemHealth Millennium Gold Virtual
- EmblemHealth Millennium Silver Value G
- EmblemHealth Prime Bronze HSA
- EmblemHealth Prime Gold Premier
- EmblemHealth Prime Gold Value
- EmblemHealth Prime Platinum Premier
- EmblemHealth Prime Silver HSA
- EmblemHealth Prime Silver Premier
- EmblemHealth Select Care Bronze Premier
- EmblemHealth Select Care Bronze Value
- EmblemHealth Select Care Gold Premier
- EmblemHealth Select Care Gold Value
- EmblemHealth Select Care Platinum Premier
- EmblemHealth Select Care Silver Premier
- EmblemHealth Select Care Silver Value
- Healthfirst Bonze 6850 Pro EPO HSA
- Healthfirst Bronze 5250 Pro EPO
- Healthfirst Bronze 8225 Pro
- Healthfirst Bronze Pro EPO HSA
- Healthfirst Platinum Pro EPO
- Healthfirst Silver 40/75/4700 Pro EPO
- Healthfirst Silver Pro EPO
- Heatlhfirst 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 Motion
- Oxford Liberty Platinum EPO
- Oxford Liberty Silver 25/50 G
- Oxford Liberty Silver EPO 40/70
- Oxford Liberty Silver EPO 50/100 ZD
- Oxford Liberty Silver HSA 4000 Motion
- Oxford Metro Bronze HSA 7000 G
- Oxford Metro Gold EPO 25/40
- Oxford Metro Gold EPO 25/40 G
- Oxford Metro Silver EPO 30/80 G
- Oxford Metro Silver EPO 50/100 ZD
2022 RESUMEN DE LA COBERTURA DE BENEFICIO (SBC)
- EmblemHealth Bridge Gold PPO
- EmblemHealth Bridge Gold Virtual
- EmblemHealth Bridge Platinum PPO
- EmblemHealth Millennium Bronze Premier G
- EmblemHealth Millennium Bronze Value G
- EmblemHealth Millennium Gold Virtual
- EmblemHealth Prime Bronze HSA
- EmblemHealth Prime Gold Premier
- EmblemHealth Prime Gold Value
- EmblemHealth Prime Platinum Premier
- EmblemHealth Prime Silver HSA
- EmblemHealth Prime Silver Premier
- EmblemHealth Select Care Bronze Premier
- EmblemHealth Select Care Bronze Value
- EmblemHealth Select Care Gold Premier
- EmblemHealth Select Care Gold Value
- EmblemHealth Select Care Platinum Premier
- EmblemHealth Select Care Silver Premier
- EmblemHealth Select Care Silver Value
- Healthfirst Bronze 5250 Pro EPO
- Healthfirst Bronze 6850 Pro EPO HSA
- Healthfirst Bronze 8225 Pro EPO
- Healthfirst Bronze Pro EPO HSA
- Healthfirst EPO Gold 1350 Pro Plus EPO
- Healthfirst Platinum Pro EPO
- Healthfirst Silver 40/75/4700 Pro EPO
- Healthfirst Silver Pro 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 Motion
- Oxford Liberty Platinum EPO
- Oxford Liberty Silver EPO 25/50 G
- Oxford Liberty Silver EPO 40/70
- Oxford liberty Silver EPO 50/100 ZD
- Oxford Liberty Silver HSA 4000 Motion
- Oxford Metro Bronze HSA 7000 G
- Oxford Metro Gold 25/40
- Oxford Metro Gold EPO 25/40 G
- Oxford Metro Silver 30/80 G
- Oxford Metro Silver EPO 50/100 ZD
SUMMARY OF BENEFITS CARRIER HIGHLIGHTS (SOB)
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.
EMBLEMHEALTH
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.
EMPIRE
To view and print an ID Card, you need to create an account and register with Empire. A Member ID number is required for registration
HEALTHFIRST
To view and print an ID Card, you need to create an account and register with Healthfirst. A Member ID number is required for registration.
OXFORD
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.
GUARDIAN
To view and print an ID card you, need to create an account and register with Guardian. A member SS# is required for registration.
SOLSTICE
To view and print your Solstice dental ID Card, you need the member date of birth, zip code and either SS# or ID Number.
To view and print your Solstice vision ID Card, you need to create an account register with DavisVision. A member ID Number, last name and date of birth are required.
UNITEDHEALTHCARE
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.