| | PacifiCare Forms |
| | All forms and plan descriptions are in portable document format (PDF).
 |
| | Some forms are available for download in Spanish.
Click the language to download the form. |
| | Form Type: Medical |
| | Form Name | Form Description
|
| |
Business Group of One Statement
English
() | To determine if a Business Group of One meets the definition of a "Small Employer" |
| |
Confirmation of Intent of Coverage
English
(8 kb) | Confirmation of Intent of Coverage |
| |
Continuation Coverage Eligibility/Enrollment Form
English
(67 kb) | Continuation Coverage Eligibility/Enrollment Form |
| |
Employee/Dependent Change Request Form
English
(69 mb) | Employee/Dependent Change Request Form |
| |
Employee/Dependent Change Request Form
English
(69 kb) | Use this form Cancel, Add or Change Coverage |
| |
HMO & PPO New Group Enrollment Checklist
English
(54 kb) | HMO & PPO New Group Enrollment Checklist |
| |
Individual Plan Waiver of Coverage Form
English
(15 kb) | For Self-Employeed Business Groups of One |
| |
IP Health Questionnaire
English
(71 kb) | Use this Medically Underwritten Individual Plan Health Questionnaire for a Business Group of One |
| |
Prescription Drup Reimbursement Form
English
() | Use this form when you have purchased a covered prescription drug at retail cost and are seeking reimbursement. |
| |
Small Business Employee Enrollment and Waiver of Coverage Form
English
(600 kb) | All eligible employees must complete, sign and forward this form to PacifiCare, whether accepting or declining coverage. |
| |
Small Business Employer Group Application
English
(117 kb) | Small Business Group Application for 1-50 Eligible Employees |
| |
Small Group PPO Basic and Standard Rx Description Form - E
English
(56 kb) | Basic and Standard Idemnity Plan Pharmacy Plan |
| |
Statement of Health Form
English
(61 kb) | Use this form for new enrollments or when transferring from HMO to PPO coverage. |
| | Form Type: Life and Disability |
| | Form Name | Form Description
|
| |
Group Life & Disability Insurance Form
English
(1.1 mb) | Enrollment Form for Group Life and Disability Insurance |
| |
Life Beneficiary Designation Form
English
(1.0 mb) | Life Beneficiary Designation Form |
| | Form Type: Dental/Vision |
| | Form Name | Form Description
|
| |
Dental & Vision Employer Group Application Form
English
(61 kb) | Small Group Employer Agreement and Application |
| |
Dental and Vision Enrollment/Change Form
English
(523 kb) | Dental and Vision Enrollment/Change Form |
| |
Dental Broker Fact Sheet
English
(768 kb) | Dental and Vision Plan Descriptions |
| |
Dental HMO Enrollment Form
English
(63 kb) | Use this form for Enrollment and Change of Status |
| |
New Case Installment Checklist
English
(54 kb) | Group/Broker New Case Installment Checklist |
| |
