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.

How to Access or Order a Member ID Card

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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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