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.

(Note: Please choose either new or existing business)

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Complete Carrier 2022 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 (1-1-22)

Aetna Employee App (1-1-22)

Aetna ACA Banking Consent

Aetna Proof of Eligibility Form

Aetna Open Enrollment Attestation Form

Aetna Employee Enrollment - Change Form (1-1-21) Spanish Version

Anthem Complete Enrollment Kit

Anthem Combined Medical & Specialty Employer App (1-1-22)

Anthem Combined Medical & Specialty Employee App (1-1-22)

Anthem Combined Medical & Specialty Employee App (1-1-22) Spanish

Anthem Electronic Funds Transfer (EFT) Authorization Form

Anthem Specialty & Medical Employee Waiver Form (1-1-22)

Anthem Specialty & Medical Employee Waiver Form (1-1-22) Spanish

Anthem Eligibility Statement

Anthem Conditions of Enrollment: Start Up Companies, PEO, Spin Off Groups

Anthem Small Group Agent Checklist

Blue Shield Complete Enrollment Kit

Blue Shield New Business Checklist

Blue Shield Employer Application (1-1-22)

Blue Shield Employee Application (1-1-22)

Blue Shield Refusal of Coverage (1-1-22)

Blue Shield Employer Application (1-1-22) Spanish version

Blue Shield Employee Application (1-1-22) Spanish version

Blue Shield Initial Payment Form

Blue Shield Owner Eligibility Statement

Blue Shield - Start-up/Spin-off Companies Eligibility Statement

California Choice Complete Enrollment Kit

California Choice New Business Checklist

California Choice Employer Application (Effective 3-1-22 through 6-1-22)

California Choice Employee Application (Effective 3-1-22 through 6-1-22)

California Choice Employee Application (Effective 4-1-22) Spanish

California Choice ACH Payment Form (1-1-22)

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 Case Submission Checklist

Choice Builder Employer Application (4-1-22)

Choice Builder Employee Application (4-1-22)

Choice Builder Employee App (Spanish) (1-1-21)

Choice Builder ACH Payment Form (1-1-22)

Choice Builder Late Submission Acknowledgement Form

Choice Builder Benefit Summaries (1-1-22)

Choice Builder Confirmation of Eligibility

Cigna + Oscar Complete Enrollment Kit

Cigna + Oscar Business Enrollment Form (California 2022)

Cigna + Oscar Employee App / Change Request Form - California 2022

Cigna + Oscar California Employee Waiver Form 2022

Cigna + Oscar ACH Authorization Form 2022

Cigna + Oscar Corporate Officer / Proprietor / Partner Verification Statement 2022

Covered California Complete Enrollment Kit

Covered California New Business Checklist

Covered California Employer Application (1-1-22)

Covered California 2022 Employee Application

Covered California Employee App (Spanish) (2021)

Covered California Late Submission Acknowledgment

Covered California How to Get a Small Business Credit

Health Net Complete Enrollment Kit

Health Net New Business Checklist

Health Net Employer App (1-1-22)

Employee Enrollment and Change Form (1-1-22)

Health Net Employee Enrollment and Change Form (Spanish) (1-1-22)

Health Net Electronic Check Form (2022)

Health Net Proof of Eligibility Statement For Sole Proprietor, Partner or Corporate Officer (2022)

Health Net Reasons for Employee Enrollment Delays

Kaiser Complete Enrollment Kit

Kaiser New Business Checklist (1-1-22)

Kaiser Employer App (1-1-22)

Kaiser Employee App (1-1-22)

Kaiser Employee App (Spanish) (1-1-22)

Kaiser Employee App (Chinese) (1-1-21)

Kaiser Owner/Officer Eligibility Statement (1-1-22)

Kaiser New Employee Eligibility (1-1-22)

Kaiser Electronic Transfer for Initial Payment Form (1-1-22)

Kaiser Employer Declination of Coverage (1-1-22) English

Kaiser Employer Declination of Coverage (1-1-22) Spanish

Kaiser Employer Declination of Coverage (1-1-22) Chinese

Kaiser Employee Declination of Coverage (1-1-22) English

Kaiser Employee Declination of Coverage (1-1-22) Spanish

Kaiser Employee Declination of Coverage (1-1-22) Chinese

Kaiser Payroll Attestation Form (1-1-22)

MediExcel Complete Enrollment Kit

MediExcel Small Group Eligibility Checklist

MediExcel Small Group Employer Application (1-1-2022)

MediExcel Large Group Employer Application (1-1-2022)

MediExcel Employee App (English) (1-1-22)

MediExcel Employee App (Spanish) (1-1-22)

MediExcel Declination of Coverage Form (English & Spanish)

MediExcel Affidavit For Enrollment Of Domestic Partner (1-1-22) English

MediExcel Affidavit For Enrollment Of Domestic Partner (1-1-22) Spanish

MediExcel Continuity of Care Form (1-1-22)

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 (1-1-22)

United Healthcare Employee App (1-1-21)

United Healthcare Scheduled Direct Debit Authorization Form (1-1-22)

United Healthcare Group Acceptance/Change Form Product and Benefit Selection Form (1-1-22)

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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