Documents & Forms Center

Members

Non-Group Conversion

PDF icon Non-Group Conversion.pdf

Members

Non-Medicare Appointment of Representation Form

PDF icon COM AOR form_3.11.15.pdf

Agents, Employers, Members

Non-Medicare Prescription Drug Reimbursement Request

PDF icon Non-Medicare Prescription Drug Reimbursement Request _ 2022 Updated.pdf

Members

Online Wellness Reimbursement Instructions

PDF icon Online-Wellness-Reimbursement-Instructions.pdf

Members

Parental Consent for Care of Minor Children

PDF icon Parental-Consent-for-Minor-Children_CHP-41.pdf

Members

Patient Health Questionnaire

PDF icon Patient Health Questionnaire (PHQ-9).pdf

Agents, Employers, Members

Pregnancy And Coverage FAQ

PDF icon Pregnancy And Coverage FAQ.pdf

Members

Principal Choice 15.50.100 Medicus 1-1-24

PDF icon Principal Choice 15.50.100 Medicus 1-1-24.pdf

Members

Principal Choice 15.50.100 Medicus 1-1-24

PDF icon Principal Choice 15.50.100 Medicus 1-1-24.pdf

Members

Principal Choice 15.50.100 Medicus 1-1-24

PDF icon Principal Choice 15.50.100 Medicus 1-1-24.pdf

Members

QI Behavioral Health Program Description 2021

PDF icon PD-BH-QI-2021.pdf

Members

QI Behavioral Health Program Description 2022

PDF icon PD-BH-QI-2022-Final1.pdf

Members

QI Commercial Program Description 2021

PDF icon PD-QI-Commercial-2021.pdf

Members

QI Commercial Program Description 2022

PDF icon PD-QI-Commercial-2022.pdf

Members

QI Medicare Program Description 2021

PDF icon PD-QI-Medicare-2021.pdf

Members

QI Medicare Program Description 2022

PDF icon PD-QI-Medicare-2022.pdf

Members

Quality Improvement Behavioral Health Program Description

PDF icon PD-BH-QI-2022.pdf

Members

Quality Improvement COM Program Description

PDF icon PD-QI-Commercial-20221.pdf

Members

Quality Improvement Program Evaluation

PDF icon 2019 QI Program Evaluation.pdf

Members

Small Employer Member Handbook - Effective 1-1-2022

PDF icon Small Employer Member Handbook - (310x plans effective 1-1-2022).pdf

Members

SMALL EMPLOYER MEMBER HANDBOOK - EFFECTIVE 1-1-2023

PDF icon 2022.05.SmMbrHbACA.pdf

Employers, Members

SMALL EMPLOYER MEMBER HANDBOOK - EFFECTIVE 1-1-2024+

PDF icon Small Employer Member Handbook - (310x plans effective 1-1-2024).pdf

Members

Small Employer Member Handbook - Keep Your Health Plan (2025)

PDF icon Small-Employer-Member-Handbook_Keep-Your-Health-Plan.pdf

Members

Small Employer Member Handbook - Keep Your Health Plan Updated 2020

PDF icon Small Employer Member Handbook - Keep Your Health Plan Updated 2020.pdf