Enrollment Information
All the information you need to enroll a new group.
Checklist
Use this enrollment checklist
to ensure all required information is submitted for processing.Order Enrollment Guides
Click here to order our 16-page, full-color enrollment guide, which introduces new clients and members to all of our medical, pharmacy and wellness programs.
Forms
Forms are in PDF format.
Updated: 03/13/2013
| Form | Purpose |
|---|---|
| Average Employee Count Calculation | Medical Loss Ratio employee count. |
| Group Enrollment Agreement | To be signed and completed for coverage |
| Small Group Certification: New Groups |
To be completed for NEW small group enrollment (see below) |
| Small Group Certification: Requalifications | To be completed for small group REQUALIFICATIONS |
| Small Group Certification: Transfers | To be completed for small group TRANSFERS |
| Group Enrollment and Changes | Used to enroll new members, change coverage, or cancel membership. |
| BlueCare Access Enrollment/Change Form | BlueCare Access Enrollment form for subscribers. NOTE: Use this form ONLY if you have BlueCare Access coverage.
|
| Waiver of Group Health Insurance Benefits | To be completed and signed ONLY if coverage is being waived. |
| 2013 Enrollment Guide |
Electronic version of our printed enrollment guides. |
The enrollment process typically takes 5-7 business days.
Enrollment is a first-in, first-out process.
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Group Enrollment FormEnrollment Agreement VHSG Rates
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