Employer Application

• Employer's Group Application

Applications and Information

• Small Employer Uniform Employee Application for Group Health Insurance
• Employee's Group Enrollment Application
• Employee's Group Medically Underwritten Enrollment Application
• Employee's Self-Funded Plan Enrollment Application
• Patient Choice Care System Selection Form
• Patient Choice Employee Guide
• Understanding Your Billing Statement Brochure (for Employers)

How to Register-Employers

Call 888-915-5618 to receive information on how to register for the secure Employer area of the site. The Group Leader will need to submit an Access agreement form based on your company size:

• Access agreement form for groups of less than 100 employees
• Access agreement form for groups of 100 or more employees

HealthSense Rewards

This discount wellness program rewards members for leading a healthy lifestyle and continuing healthy habits.

• Visit the HealthSense Rewards area...

CMS (Medicare Part D) Information

Creditable Coverage Disclosure Notice to CMS The Centers for Medicare & Medicaid Services (CMS) recently issued additional information concerning Disclosure Notices. The provisions require group health plans that currently provide prescription drug coverage to Medicare Part D eligible individuals must disclose to CMS if the coverage is “creditable prescription drug coverage.” The Disclosure Notice must be submitted to CMS on an annual basis, and upon any change that affects whether the drug coverage is creditable.

• Click here to access the CMS directions related to this form
• Click here to visit the CMS Web site

HIPAA Forms and Documents

This provides a collection of HIPAA forms and documents, particularly those regarding PHI (Personal Health Information).

• Notice of Privacy Practices
• Appeals/Grievance Authorized Representative Form
• Authorization for WPS to Disclose Health Information
• General Authorization to Use and Disclose Health Information
• Request to Access PHI
• Request to Amend PHI

Fraud Forms

• Special Investigations Unit