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Forms Finder

Select the size of your group and the carrier you want to work with. Then specify whether it’s new or existing business, then select the product type. You can also search for additional miscellaneous carrier enrollment tools. Please contact sales@dickerson-group.com if you are having trouble finding your desired form.

  • New Business Effective Date

  • Existing Business Effective Date

  • Group Size

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How to Access or Order a Member ID Card
Click Here for Additional Carrier Sales Materials

Complete Carrier 2021 Enrollment Kits

See below for complete enrollment kits for each carrier. Please note that the date in parenthesis indicates the effective date of the form.

All forms, even if a few months old, are the most up-to-date.

Aetna Complete Enrollment Kit
Aetna New Business Checklist
Aetna Employer App (1-1-21)
Aetna Employee Enrollment / Change Form (1-1-21)
Aetna ACA Banking Consent
Aetna Proof of Eligibility Form
Aetna FTE Certification
Aetna Open Enrollment Attestation Form

Anthem Complete Enrollment Kit
Anthem Combined Medical & Speciality Employer App (1-1-21)
Anthem Combined Medical & Speciality Employee App (1-1-21)
Anthem Combined Medical & Speciality Employee App (Spanish) (1-1-21)
Anthem Electronic/Recurring Payment Option
Anthem Specialty & Medical Employee Waiver Form
Anthem Specialty & Medical Employee Waiver Form (Spanish)
Anthem Eligibility Statement
Anthem Conditions of Enrollment: Start Up Companies, PEO, Spin Off Groups

Blue Shield Complete Enrollment Kit
Blue Shield New Business Checklist
Blue Shield Employer Application (1-1-21)
Blue Shield Employer Application (Spanish) (1-1-21)
Blue Shield Employee Application (1-1-21)
Blue Shield Employee Application (Spanish) (1-1-21)
Blue Shield Refusal of Coverage
Blue Shield Initial Payment Form
Blue Shield Owner Eligibility Statement
Blue Shield Start-Up/Spin-Off Group Eligibility Statement

California Choice Complete Enrollment Kit
California Choice New Business Checklist
California Choice Employer App (1-1-21)
California Choice Employee Enrollment App (1-1-21)
California Choice ACH Payment Form
California Choice Owner/Partner Statement
California Choice Case Submission Acknowledgement
California Choice Group Size Attestation
California Choice Confirmation of Eligibility

Choice Builder Complete Enrollment Kit
Choice Builder New Business Checklist
Choice Builder Employer App (1-1-21)
Choice Builder Employee App (1-1-21)
Choice Builder Employee App (Spanish) (1-1-21)
Choice Builder ACH Payment Form
Choice Builder Late Submission Acknowledgment Form
Choice Builder Benefit Summaries Quote
Choice Builder Confirmation of Eligibility

Covered California Complete Enrollment Kit
Covered California New Business Checklist
Covered California Employer App (1-1-21)
Covered California Employee App (1-1-21)
Covered California Late Submission Acknowledgment

Health Net Complete Enrollment Kit
Health Net New Business Checklist
Health Net Employer App (1-1-21)
Health Net Employee App (1-1-21)
Health Net Employee / Change Request Form (1-1-21)
Health Net Electronic Check Form
Health Net Proof of Eligibility
Health Net ACH Form
Health Net Reasons for Employee Enrollment Delays

Kaiser Complete Enrollment Kit
Kaiser New Business Checklist
Kaiser Employer App (1-1-21)
Kaiser Employee App (1-1-21)
Kaiser Employee App (Spanish) (1-1-21)
Kaiser Employee App (Chinese) (1-1-21)
Kaiser Owner/Officer Eligibility Statement
Kaiser New Employee Eligibility
Kaiser Electronic Transfer for Payment Form
Kaiser Declination of Coverage
Kaiser Declination of Coverage (Spanish)
Kaiser Declination of Coverage (Chinese)
Kaiser Employer Attestation Declination of Coverage
Kaiser Payroll Attestation Form

MediExcel Complete Enrollment Kit
MediExcel Small Group Eligibility Checklist
MediExcel Employer App (1-1-21)
MediExcel Employee App (English & Spanish) (1-1-21)
MediExcel Declination of Coverage Form (English & Spanish)
MediExcel Affidavit For Enrollment Of Domestic Partner (English & Spanish)
MediExcel Continuity of Care Form
MediExcel SENTRI Pass Reimbursement Form
MediExcel Request Form for Reimbursement of Healthcare Services

Oscar Complete Enrollment Kit
Oscar Small Group Eligibility Checklist
Oscar Employer App (1-1-21)
Oscar Employee App (1-1-21)
Oscar Employee Waiver Form
Oscar ACH Authorization Form
Oscar Corporate Officer Proprietor or Partnership Form

United Healthcare Complete Enrollment Kit
United Healthcare New Business Checklist
United Healthcare Employer App (1-1-21)
United Healthcare Employee App (1-1-21)
United Healthcare Direct Debit Authorization Form
United Healthcare Product Selection Form
United Healthcare Group Acceptance/Change Form Product and Benefit Selection Form

Benefit Summaries

• Aetna

• Anthem Blue Cross

• Blue Shield

• CaliforniaChoice ® 

• Choice Builder® 

• Health Net

• Kaiser Permanente

• Oscar Health

• SIMNSA

 

Summary of Benefits and Coverage (SBC)

• Aetna

• Anthem Blue Cross

• Blue Shield

• CaliforniaChoice ®

• Health Net

• Kaiser Permanente

• MediExcel

• Oscar Health

Covered California for Small Business

• Blue Shield

• CCHP Health Plan

• Health Net

• Kaiser Permanente

• Sharp

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