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Group Enrollment and Termination Forms Simplify Tasks

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If you are submitting group or division enrollments or terminations via mail or fax, your life could be easier.  Instead, you could be using online forms that collect and store all the information we need to complete your request. 

For enrollment, we need:

  • Group contact information
  • In- and out-of-network coinsurance, co-pay and deductible amounts
  • Timely filing limit
  • Name and toll-free number of the utilization management company
  • Contractholder, claim processing and invoicing information
  • Employee count

For termination, we need:

  • Payer and group contact information
  • Policy numbers
  • Termination date
  • Run-out arrangement

You will receive immediate confirmation that we have received your request. 

The first time you open one of the forms, it may take a few seconds to appear on your screen.

If you have additional questions about the forms, contact your payer relations representative or e-mail Payer Relations.