Use these categories for quick access to the forms you need. If you require further assistance, please contact us.
Our individual plans page has forms and other materials available to producers.
Our small group page has forms and other materials available to producers.
Our large group page has forms and other materials available to producers.
By the 1st of each month:
Use these forms to enroll/renew or renew your group onto a personal funding account, such as an FSA, HRA, or HSA.
Personal Funding Account Enrollment and Change Application
Personal Funding Account Setup Form - For Metallic Groups up to 50
View or print this form
This section provides release of information forms
Authorization for Release of Healthcare Information and Records
Authorization for Release of Psychotherapy Notes
Disclosure Accounting Request
Request for Amendment of Record
Request for Inspection of Records
Affidavit of Domestic Partnership
Individual Domestic Partner Eligibility Requirements
AFT Authorization Form for Individual Major Medical
HSA Authorization Form for UMB Bank
Producer of Record Change Form
Preventive Screening Services (non-grandfathered plans)
Student Status Verification
Waiver of Coverage
2015 Grandfathered Plan Rate Sheet
2016 Grandfathered Plan Rate Sheet
2015 Non-Grandfathered Plan Rate Sheet (Safeguard suite)
2015 Non-Grandfathered Plan Rate Sheet (Alaska Best Care Suite) - For closed plans with original start dates from April 1, 2010 to April 15, 2010
2015 Non-Grandfathered Plan Rate Sheet (Alaska Peak suite) - For closed plans with original start dates from May 1, 2010 until Dec. 15, 2010
2016 Non-Grandfathered Plan Rates - For plans with start dates from May 1, 2016
Request for Certification of Disabled Dependent
Deductible Credit Form
Electronic Funding Authorization
To order individual products and supplies:
Fill out the:
Producer Supply Form
Save a copy for your records.
Email it to Producer Supply. Or fax the completed form to 907-258-1619.