First National Administrators - Health Insurance Enrollment Forms

Health Insurance Enrollment Forms

Below are the Carrier Forms needed to submit your group to First National Administrators.

Aetna NY
Aetna NJ
Aetna CT
Aetna HSA
AmeriHealth NJ
Chartis Limited Medical
Easy Choice (Formerly Atlantis)
Emblem Health NY
Empire BCBS NY - Large Group
HealthPass
HIP NY
Horizon BCBS NJ
LIA Health Alliance NY
Oxford NY
Oxford NJ
Oxford CT
United Healthcare - Large Group

Aetna NY

FNA Aetna NY Submission Requirements^{(4-14-10) 2012}
A etna NY New Business Case Submission Checklist ^{(14.03.947.1-NY D (4/11) ) 2012}
Aetna NY Small Group Employer Application^{(GR-96241-NY (10/10) R-POD M) 2012}
Aetna NY Small Group Employee Enrollment/Change Form ^{(GR-67834-16 (10/10) NY-SGB R-PODL ) 2012}
Aetna NY Addendum to New Business Input Documents Mandatory Requirement for Health Care Reform ^{(GR-68720 (7/11) ) 2012}
Employer Verification Form ^{(EI930 (6/10) ) & (EI930B (6/10) ) 2012}
Proof of Eligibility Form ^{(05/19/06) 2012}
Associated Companies Form ^{(9/9/09) 2012}
Aetna Late Paperwork Submission Form ^{(GR-68702 (2-11) ) 2012}
Aetna NY Employer Funding Certification and Statement of Understanding for Small Employers ^{(14.32.902.1-NY (5/10) ) 2012}
Aetna Joinder Agreement ^{(GR-67987 (4-04) R-POD ) 2012}
Aetna Declaration of Domestic Partnership ²⁰¹²
Aetna NYC Community Plan Guide ²⁰¹²
Aetna NY Provider Network Brochure ^{14.03.152.1-NY (9/09) 2012}
Aetna NYCCP Individual PCP List ²⁰¹²
Complete Kit ²⁰¹²

Aetna NJ

FNA Aetna NJ Submission Requirements ^{(Rev 10/5/11) 2012}
Aetna NJ New Business Case Submission Checklist^{(14.03.947.1-NJ A (4/11) ) 2012}
Aetna NJ Addendum to New Business Input Documents Mandatory Requirement for Health Care Reform ^{(GR-68720 (7-11) ) 2012}
Aetna NJ Application for a Small Group Health Benefits Policy ^{(GR-96241-NJ (11-09) R-POD H) 2012}
Aetna NJ Employer Certification ^{(GR-68099 (1-11) R-POD A) 2012}
Aetna NJ Small Group Enrollment/Change Request ^{(MBNL (2-05) NJ-HINT SGB GR-67834-27 (11-09) R-POD G) 2012}
Aetna NJ Small Employer Health Benefits Waiver of Coverage ^{(GR-67618 (5-05) R-POD) 2012}
Aetna NJ Proof of Eligibility Form ^{(6/25/04) 2012}
Aetna NJ HSA Declaration of Understanding ^{(41.03.102.1-NJ (2/06) ) 2012}
Aetna NJ Small Employer Funding Certification and Statement of Understanding Attestation Form ^{(14.32.902.1-NJ A (2/10) ) 2012}
Aetna NJ Associated Companies (9/9/09) 2012
Aetna NJ Small Group Underwriting PEO (Professonal Employer Organization)/Leased Employees ^{(GR-68509 (1-09) ) 2012}
Aetna NJ Request for Participation and Joinder Agreement^{(GR-67987 (4-04) R-POD) 2012}
Aetna NJ New Business Late Submission Form ^{(GR-68702 (2-11) ) 2012}
Complete Kit ²⁰¹²

Aetna CT

FNA Aetna CT Submission Requirements 2012
Aetna CT New Business Case Submission Checklist ^{(14.03.947.1-CT E (4/11) ) 2012}
Aetna Addendum to New Business Input Documents Mandatory Requirement for Health Care Reform ^{(GR-68720 (7-11) 2012}
Aetna Employer Information Form ^{(EI930 (6-10) & (EI930B (6-10) 2012}
Aetna CT Small Group Business Employee Enrollment/Change Form ^{(GR-67834-24 (7/11) CT - SGB R-POD I) 2012}
Aetna CT Small Group Business Employer Application ^{(GR-96241-CT (7-11) R-POD M) 2012}
Aetna Small Employer Health Benefits Waiver of Coverage ^{(14.09.302.1-CT) 2012}
Aetna Family Health Statement ^{(GR-68102-1 (4-05) CT-SGB R-POD) 2012}
Aetna Associated Companies^{(9/9/09) 2012}
Aetna Request for Participation and Joinder Agreement ^{(GR-67987 (4-04) R-POD) 2012}
Aetna New Business Late Submission Form ^{(GR-68702 (2-11) ) 2012}
Complete Kit ²⁰¹²

Aetna HSA

FNA Aetna HSA Submission Requirements ²⁰¹²
Aetna Health Equity HSA Welcome/How to Enroll ^{(14.36.901.1) 2012}
Aetna Health Equity HSA Brochure^{(GC0N07-01) 2012}
Aetna SBS Brochure ^{(64.10.300.1-NY A (7/11) ) 2012}
Aetna HealthFund HSA Employer Enrollment Form ^{(Aetna_Employer_HSA_200911) 2012}
Aetna HealthFund HSA Employee Enrollment Form ^{(Aetna HealthFund HSA Employee Enrollment Form _200912) 2012}
Aetna HealthFund HSA Beneficiary Designation Form ^{(Aetna Health Fund HSA Benificiary Designation Form _20101029) 2012}
Aetna Health Equity HSA Custodial Agreement ^{(HEQ HSA CUSTODIAL AGREEMENT 20110616) 2012}
Aetna HealthFund HSA Rollover/Transfer Request Form ^{(Aetna_HSA_Transfer_Rollover Form_200911) 2012}
Aetna NY Employer Funding Certification and Statement of Understanding for Small Group ^{(14.32.902.1-NY (5/10) 2012}
Aetna NJ Small Employer Funding Certification and Statement of Understanding Attestation Form ^{(14.32.902.1-NJ A (2/10) 2012}
Aetna CT Employer/Broker Funding Certification for Small Group Plans with In-Network Deductible ^{(14.32.902.1-CT B (12/10) 2012}
Aetna HSA Fee Schedule ^{(01/11 F10) 2012}
Complete Kit ²⁰¹²

AmeriHealth NJ

FNA Amerihealth Submission Requirements ²⁰¹²
AmeriHealth Account Installation Checklist^{(4/08) 2012}
AmeriHealth Employee Enrollment/Change Application ^{(ahenchga.pm65) 2012}
AmeriHealth Enrollment/Change Request ^{(01412 05/07) 2012}
AmeriHealth Dependent to Age 31 Enrollment Application ²⁰¹²
AmeriHealth Employer Authorization Letter for EFT of Initial Premium ²⁰¹²
AmeriHealth Plan Change Letter ²⁰¹²
How to Sell AmeriHealth Underwriting and Administrative Guidelines ^{(10/16/2008) 2012}
AmeriHealth Small Employer Health Benefits Waiver of Coverage ^{(6761 12/03) 2012}
AmeriHealth New Jersey Small Employer Certification ^{(AHNJ SEH Cert rev. 4/13/11) 2012}
AmeriHealth Declaration of Understanding (PPO)²⁰¹²
AmeriHealth Declaration of Understanding (EPO) ²⁰¹²
Complete Kit ²⁰¹²

Chartis Limited Medical

FNA Chartis Submission Requirements ²⁰¹²
Chartis Sold Case Form ²⁰¹²
Chartis Individual Enrollment Form ²⁰¹²
Chartis Premium Calculation Sheet ²⁰¹²
Chartis Add/Term Form²⁰¹²
Complete Kit ²⁰¹²

Easy Choice (formerly Atlantis)

FNA Easy Choice Submission Requirements ²⁰¹²
Easy Choice Case Installation Form^{(ECHPNY-00115 S&M Revised 12/09) 2012}
Easy Choice Producer Compensation Disclosure Statement^{(COMP 14.0 Producer Compensation Transparency) 2012}
Required With ALL New Business Case Submissions
Easy Choice Group Agreement Form^{(AHP-00087 Rev01092011) 2012}
Easy Choice Notice of Enrollment Period And Waiver Form^{(AHP-00116 Revised 4/08) 2012}
Easy Choice Previous Insurance Coverage Form^{(AHP-00121 Revised 04/08) 2012}
Easy Choice Employee Enrollment Form ^{(AHP-00085 EmployeeEnrollmentForm v3.) 2012}
Easy Choice Credit Card/Debit Card Payment Authorization ^{(AHP-00062 B&E Credit/ACH Form) 2012}
Easy Choice Declaration of Domestic Partnership & Declaration of Termination of Domestic Partnership ²⁰¹²
Complete Kit ²⁰¹²

Emblem Health NY

Empire BCBS - Large Group

FNA Large Group Underwriting Requirements ²⁰¹²
FNA Large Group Request for Quote ²⁰¹²

HealthPass

FNA HealthPass Submission Requirements *
HealthPass Eligilibility Guidelines ^{(HPS-13 v1of1 1.01.12) 2012}
HealthPass Enrollment Checklist ^{(HPS-020 v1of2 1.01.12) 2012}
HealthPass Notice of Election^{(HPS-011 v1 of 2 1.1.12) 2012}
HealthPass Enrollment/Change Form ^{(HPS-010-v1of1 1.01.12) 2012}
HealthPass Letter of Certification ²⁰¹²
HealthPass Electronic Funds Transfer Form ^{(HPS-080 v1of1 1.01.12) 2012}
HealthPass Network Availability^{(HPS-018 v1of1 1.01.12) 2012}
HealthPass Pharmacy Options^{(HPS-019 v1of2 1.01.12) 2012}
HealthPass Declaration of Cohabitation ^{(HPS-601 v1of1 1.12) 2012}
HealthPass Domestic Partner Registration Info Sheet ²⁰¹²
Complete Kit ²⁰¹²

HIP NY

Horizon BCBS NJ

Miscellaneous Forms

Horizon Conversion Form

LIA Health Alliance NY

Oxford NY (Freedom Plan)

FNA Oxford Submission Requirements ²⁰¹²
New York Community-Rated Small Group Application ^{(OHPNY GA S 811 1558 Rev 18) 2012}
Group Affirmation Letter ^{(NY-00-776) 2012}
New York Member Enrollment Form - OHP^{(OHPNY MEFLS 1109 333 Rev 11) 2012}
Dental Enrollment Form^{(OHP DE 10/96 040 Rev R 5) 2012}
New York Health Benefits Waiver of Coverage ^{(OHINY Waiver LS 711 3313 Rev 6) 2012}
Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
Complete Kit ²⁰¹²

Oxford NY (Freedom Plan Select)

FNA Oxford Submission Requirements ²⁰¹²
New York Community-Rated Small Group Application^{(OHPNY GA S 811 1558 Rev 18) 2012}
Group Affirmation Letter^{(NY-00-776) 2012}
New York Member Enrollment Form - OHP^{(OHPNY MEFLS 1109 333 Rev 11) 2012}
Dental Enrollment Form^{(OHP DE 10/96 040 Rev R 5) 2012}
New York Health Benefits Waiver of Coverage^{(OHINY Waiver LS 711 3313 Rev 6) 2012}
Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
Complete Kit ²⁰¹²

Oxford NY (Freedom Plan Metro & Freedom Plan Metro Access)

FNA Oxford Submission Requirements ²⁰¹²
NY Small Group Application - OHI^{(OHINY GA 811 4228 R31) 2012}
Group Affirmation Letter^{(NY-00-776) 2012}
New York Member Enrollment Form - OHI^{(OHINY MEFLS 1109 4318 Rev 8) 2012}
Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}
New York Health Benefits Waiver of Coverage^{(OHINY Waiver LS 711 3313 Rev 6) 2012}
Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
Complete Kit²⁰¹²

Oxford NY (Freedom Plan Direct)

FNA Oxford Submission Requirements ²⁰¹²
NY Small Group Application - OHI ^{(OHINY GA 811 4228 R31) 2012}
Group Affirmation Letter^{(NY-00-776) 2012}
New York Member Enrollment Form - OHI^{(OHINY MEFLS 1109 4318 Rev 8) 2012}
Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}
New York Health Benefits Waiver of Coverage^{(OHINY Waiver LS 711 3313 Rev 6) 2012}
Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
Complete Kit ²⁰¹²

Oxford NY (Liberty Plan)

FNA Oxford Submission Requirements ²⁰¹²
NY Small Community-Rated Group Application^{(OHPNY GA S 811 1558 Rev 18) 2012}
Group Affirmation Letter^{(NY-00-776) 2012}
Member Enrollment Form^{(OHPNY MEFLS 1109 333 Rev 11) 2012}
Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}
New York Health Benefits Waiver of Coverage^{(OHINY Waiver LS 711 3313 Rev 6) 2012}
Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
Complete Kit ²⁰¹²

Oxford NY (Liberty Plan Select)

FNA Oxford Submission Requirements ²⁰¹²
NY Small Communit-Rated Group Application ^{(OHPNY GA S 811 1558 Rev 18) 2012}
Group Affirmation Letter ^{(NY-00-776) 2012}
Member Enrollment Form^{(OHPNY MEFLS 1109 333 Rev 11) 2012}
Dental Enrollment Form^{(OHP DE 10/96 040 Rev 5) 2012}
New York Health Benefits Waiver of Coverage^{(OHINY Waiver LS 711 3313 Rev 6) 2012}
Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
Complete Kit ²⁰¹²

Oxford NY (Liberty Plan Metro & Liberty Plan Metro Access)

FNA Oxford Submission Requirements ²⁰¹²
NY Small Group Application (OHI) ^{(OHINY GA S 811 4228 R31) 2012}
Group Affirmation Letter^{(NY-00-776) 2012}
New York Member Enrollment Form - OHI ^{(OHINY MEFLS 1109 4318 Rev 8) 2012}
Dental Enrollment Form ^{(OHP DE 10/96 040 Rev 5) 2012}
New York Health Benefits Waiver of Coverage^{(OHINY Waiver LS 711 3313 Rev 6) 2012}
Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
Complete Kit ²⁰¹²

Oxford NY (Liberty Plan Direct)

FNA Oxford Submission Requirements ²⁰¹²
NY Small Group Application (OHI)^{(OHINY GA S 811 4228 R31) 2012}
Group Affirmation Letter^{(NY-00-776) 2012}
New York Member Enrollment Form - OHI^{(OHINY MEFLS 1109 4318 Rev 8) 2012}
Dental Enrollment Form^{(OHP DE 10/96 040 Rev 5) 2012}
New York Health Benefits Waiver of Coverage^{(OHINY Waiver LS 711 3313 Rev 6) 2012}
Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
Complete Kit ²⁰¹²

Oxford NY (Liberty HMO)

FNA Oxford Submission Requirements ²⁰¹²
NY Liberty HMO Small Group Application^{(OHPNY GA HMO 811 10173 R5) 2012}
Group Affirmation Letter ^{(NY-00-776) 2012}
Member Enrollment Form (OHP)^{(OHPNY MEFLS 1207 333 Rev 9) 2012}
New York Health Benefits Waiver of Coverage^{(OHINY Waiver LS 711 3313 Rev 6) 2012}
Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
Complete Kit²⁰¹²

Oxford NY (Exclusive Plan Metro)

FNA Oxford Submission Requirements ²⁰¹²
NY Small Group Application - (OHI)^{(OHINY GA S 811 4228 R31) 2012}
Group Affirmation Letter^{(NY-00-776) 2012}
N ew York Member Enrollment Form - OHI^{(OHINY MEFLS 1109 4318 Rev 8) 2012}
Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}
New York Health Benefits Waiver of Coverage^{(OHINY Waiver LS 711 3313 Rev 6) 2012}
Add/Term/Change Form ^{(MS 07-422 003 REV 8) 2012}
Complete Kit ²⁰¹²

Oxford NY (HSA)

GROUP

FNA Oxford Submission Requirements ²⁰¹²
NY Small Group Application - (OHI) ^{(OHINY GA S 1007 4228 R31) 2012}
HSA Employer Set-Up Bank Notification^{(06-327 7423 R4) 2012}

MEMBER

Account Holder Brochure ^{(045-0136 9/04) 2012}
HSA Card Agreement - OptumHealth Bank ^{(12/07 OH-FSV-DM-21208-993) 2012}
HSA Privacy Notice - OptumHealth Bank^{(045-0132 11/07) 2012}
HSA Custodial and Deposit Agreement - OptumHealth Bank ^{(045-0131 11/07) 2012}
HSA Application - OptumHealth Bank ^{(045-0130 11/07) 2012}
Complete Kit ²⁰¹²

Oxford NY (MyPlan)

FNA Oxford Submission Requirements ²⁰¹²
NY Small Group Application (OHI) ^{(OHINY GA S 811 4228 R31) 2012}
New York Member Enrollment Form - OHI^{(OHINY MEFLS 1109 4318 REV8) 2012}
Oxford MyPlan Health Reserve Account Group Application 2012
Oxford MyPlan Check Drafting Authorization 2012
Oxford MyPlan Claim Disbursement ACH Authorization Release 2012
Complete Kit ²⁰¹²

Oxford NY (Healthy NY)

FNA Oxford Submission Requirements ²⁰¹²
Healthy New York Small Employer Group Application ^{(OHPNY GA HNY S 1111 4526 R18) 2012}
Healthy New York Application for Individuals and Sole Proprietors^{(OHP NY GA HNY ISP 1111 4529 R20) 2012}
Healthy New York Group Enrollment Agreement^{(OHPNY HNY GEA 605) 2012}
Healthy New York Member Enrollment Form ^{(OHP HNY MEF 1010 4524 R6) 2012}
Healthy New York Re-certification for Small Employers^{(OHP NY Recert HNY S 1111 6473 R14) 2012}
Healthy New York Re-certification for Individuals and Sole Proprietors^{(OHP NY Recert HNY ISP 1109 6472 R11) 2012}
Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}
New York Health Benefits Waiver of Coverage^{(OHINY Waiver LS 711 3313 Rev 6) 2012}
Complete Kit ²⁰¹²

Oxford NY (USA)

FNA Oxford Submission Requirements ²⁰¹²
Member Enrollment Form ^{(OHINY MEFLS 1109 4318 REV8) 2012}
New York Small Group Oxford USA Addendum^{(OHINY GA S OXUSA 307 4789 Rev 21) 2012}
New York Health Benefits Waiver of Coverage ^{(OHINY Waiver LS 711 3313 Rev 6) 2012}
Complete Kit ²⁰¹²

Oxford NJ

Oxford NJ (Freedom Plan)

FNA Oxford NJ Submission Requirements ²⁰¹²

Application for a Small Employer Health Benefits Policy - OHI^{(OHI NJ SM APP 5/04 1087 R18) 2012}

NJ Small Member Enrollment/Change Request Form - OHI^{(OHI NJ S MEF 7/04 6856 R7) 2012}

NJ Small Employer Health Benefits Waiver of Coverage ^{(OHI NJ SEH WC 1086 R5)2012}

NJ Small Employer Certification^{(SEH-SEC-6/94-1 NJ-11-018 1089 R4) 2012}

Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}

Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form^{(OHPNJ MEF LS HINT SUPP 406 #8831 R1}

Complete Kit²⁰¹²

Oxford NJ (Freedom Plan Direct)

FNA Oxford NJ Submission Requirements ²⁰¹²

Application for a Small Employer Health Benefits Policy - OHI^{(OHI NJ SM APP 5/04 1087 R18) 2012}

NJ Small Member Enrollment/Change Request Form - OHI^{(OHI NJ S MEF 7/04 6856 R7) 2012}

NJ Small Employer Health Benefits Waiver of Coverage^{(OHI NJ SEH WC 1086 R5) 2012}

NJ Small Employer Certification^{(SEH-SEC-6/94-1 NJ-11-018 1089 R4) 2012}

Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5)2012}

Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form^{(OHPNJ MEF LS HINT SUPP 406 #8831 R1) 2012}

Complete Kit²⁰¹²

Oxford NJ (Freedom Plan PPO)

FNA Oxford NJ Submission Requirements ²⁰¹²

Application for a Small Employer Health Benefits Policy - OHI^{(OHI NJ SM APP 5/04 1087 R18) 2012}

NJ Small Member Enrollment/Change Request Form - OHI ^{(OHI NJ S MEF 7/04 6856 R7) 2012}

NJ Small Employer Health Benefits Waiver of Coverage ^{(OHI NJ SEH WC 1086 R5) 2012}

NJ Small Employer Certification ^{(SEH-SEC-6/94-1 NJ-11-018 1089 R4) 2012}

Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}

Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form ^{(OHPNJ MEF LS HINT SUPP 406 #8831 R1) 2012}

Complete Kit ²⁰¹²

Oxford NJ (Liberty Plan)

FNA Oxford NJ Submission Requirements ²⁰¹²

Application for a Small Employer Health Benefits Policy - OHI ^{(OHI NJ SM APP 5/04 1087 R18) 2012}

NJ Small Member Enrollment/Change Request Form - OHI^{(OHI NJ S MEF 7/04 6856 R7) 2012}

NJ Small Employer Health Benefits Waiver of Coverage^{(OHI NJ SEH WC 1086 R5) 2012}

NJ Small Employer Certification ^{(SEH-SEC-6/94-1 NJ-11-018 1089 R4) 2012}

Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}

Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form^{(OHPNJ MEF LS HINT SUPP 406 #8831 R1) 2012}

Complete Kit ²⁰¹²

Oxford NJ (Liberty Plan Direct)

FNA Oxford NJ Submission Requirements ²⁰¹²

Application for a Small Employer Health Benefits Policy - OHI ^{(OHI NJ SM APP 5/04 1087 R18) 2012}

NJ Small Member Enrollment/Change Request Form - OHI ^{(OHI NJ S MEF 7/04 6856 R7) 2012}

NJ Small Employer Health Benefits Waiver of Coverage ^{(OHI NJ SEH WC 1086 R5) 2012}

NJ Small Employer Certification ^{(SEH-SEC-6/94-1 NJ-11-018 1089 R4) 2012}

Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}

Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form ^{(OHPNJ MEF LS HINT SUPP 406 #8831 R1) 2012}

Complete Kit ²⁰¹²

Oxford NJ (Liberty Plan PPO)

FNA Oxford NJ Submission Requirements 2012

Application for a Small Employer Health Benefits Policy - OHI ^{(OHI NJ SM APP 5/04 1087 R18) 2012}

NJ Small Member Enrollment/Change Request Form - OHI ^{(OHI NJ S MEF 7/04 6856 R7)} ²⁰¹²

NJ Small Employer Health Benefits Waiver of Coverage ^{(OHI NJ SEH WC 1086 R5) 2012}

NJ Small Employer Certification ^{(SEH-SEC-6/94-1 NJ-11-018 1089 R4) 2012}

Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}

Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form^{(OHPNJ MEF LS HINT SUPP 406 #8831 R1) 2012}

Complete Kit²⁰¹²

Oxford NJ (HMO)

FNA Oxford NJ Submission Requirements 2012

Small Group Application - OHP ^{(OHP NJ SM APP (5/04) 7026 R14) 2012}

NJ Small Member Enrollment/Change Request Form - OHP ^{(OHP NJ S MEF 7/04 6855 R7) 2012}

NJ Small Employer Health Benefits Waiver of Coverage^{(OHI NJ SEH WC 1086 R5) 2012}

NJ Small Employer Certification^{(SEH-SEC-6/94-1 NJ-11-018 1089 R4) 2012}

NJ Small Group Attachment A - OHP^{(NJ-10-895 6836 R6) 2012}

Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}

Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form ^{(OHPNJ MEF LS HINT SUPP 406 #8831 R1) 2012}

Complete Kit ²⁰¹²

Oxford NJ (USA)

FNA Oxford NJ Submission Requirements 2012

NJ Small Group Oxford USA Addendum^{(NJ-07-606 4787 Rev 17) 2012}

Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form ^{(OHPNJ MEF LS HINT SUPP 406 #8831 R1) 2012}

Complete Kit²⁰¹²

Oxford NJ (HSA)

FNA Oxford NJ Submission Requirements ²⁰¹²

GROUP

NJ Large Group Application - OHI ^{(OHI LG GR APP 708 4744 Rev 17) 2012}

HSA Bank Notification Form ^{(06-327 7423 R4) 2012}

NJ Certificate of Understanding - Small Group ^{(OHINJ DOU DRCT HSA S 206 8766-Small Group) 2012}

Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form^{(OHPNJ MEF LS HINT SUPP 406 #8831 R1) 2012}

MEMBER

Account Holder Brochure^{(045-0136 9/04) 2012}

HSA Card Agreement - OptumHealth Bank ^{(12/07 OH-FSV-DM-21208-993) 2012}

HSA Privacy Notice - OptumHealth Bank^{(045-0132 11/07) 2012}

HSA Custodial and Deposit Agreement - OptumHealth Bank^{(045-0131 11/07) 2012}

HSA Application - OptumHealth Bank^{(045-0130 11/07) 2012}

Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form^{(OHPNJ MEF LS HINT SUPP 406 #8831 R1) 2012}

Complete Kit ²⁰¹²

Oxford NJ (MyPlan)

FNA Oxford NJ Submission Requirements 2012

Application for a Small Employer Health Benefits Policy - OHI ^{(OHI NJ SM APP 5/04 1087 R18) 2012}

NJ Small Member Enrollment/Change Request Form - OHI ^{(OHI NJ S MEF 7/04 6856 R7) 2012}

NJ Small Employer Health Benefits Waiver of Coverage ^{(OHI NJ SEH WC 1086 R5) 2012}

Oxford MyPlan Health Reserve Account Group Application

Oxford MyPlan Check Drafting Authorization

Oxford MyPlan Claim Disbursement ACH Authorization Release

Temporary Supplemental Healthcare Information Networks & Technologies (HINT) Form ^{(OH PNJ MEF LS HINT SUPP 406 #8831 R1) 2012}

Kit ²⁰¹²

Oxford CT

Oxford CT (Freedom Plan)

FNA Oxford CT Submission Requirements 2012

Connecticut Small Group Application ^{(OHPCT GA S 311 1768 R15) 2012}

Connecticut Small Group Attachment A - OHP^{(OHPCT UG S 5/04 5806 Rev 6) 2012}

Member Enrollment and Physician Selection Form^{(CT-10-255 4207 REV9) 2012}

Connecticut Health Benefits Waiver of Coverage^{(CT-03-756 6424 R5) 2012}

Connecticut Family Health Statement^{(CT-11-0038 6357 R5)2012}

Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}

CT Premium Payments for Termed Employees^{(CT-09-608) 2012}

Employer Request for Premium Credit Form ^{(CT-10-541) 2012}

Complete Kit ²⁰¹²

Oxford CT (Freedom Plan Select)

FNA Oxford CT Submission Requirements 2012

Connecticut Small Group Application ^{(OHPCT GA S 311 1768 R15) 2012}

Connecticut Small Group Attachment A - OHP^{(OHPCT UG S 5/04 5806 Rev 6) 2012}

Member Enrollment and Physician Selection Form ^{(CT-10-255 4207 REV9) 2012}

Connecticut Health Benefits Waiver of Coverage^{(CT-03-756 6424 R5) 2012}

Connecticut Family Health Statement^{(CT-11-0038 6357 R5) 2012}

Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}

CT Premium Payments for Termed Employees^{(CT-09-608) 2012}

Employer Request for Premium Credit Form ^{(CT-10-541) 2012}

Complete Kit ²⁰¹²

Oxford CT (Freedom Plan Value Option)

FNA Oxford CT Submission Requirements 2012

Connecticut Small Group Application - OHI (5121) ^{(OHICT GA S 311 5121 R17) 2012}

Connecticut Member Enrollment Form - OHI ^{(CT-10-254 5123 Rev 9) 2012}

Connecticut Health Benefits Waiver of Coverage ^{(CT-03-756 6424 R5) 2012}

Connecticut Family Health Statement ^{(CT-11-0038 6357 R5) 2012}

Connecticut Small Group Attachment A-OHI ^{(OHICT UG S 5/04 5798 Rev 6) 2012}

CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}

Employer Request for Premium Credit Form ^{(CT-10-541) 2012}

Complete Kit ²⁰¹²

Oxford CT (Freedom Plan Laurel)

FNA Oxford CT Submission Requirements 2012

Connecticut Small Group Application ^{(OHPCT GA S 311 1768 R15) 2012}

Connecticut Small Group Attachment A - OHP ^{(OHPCT UG S 5/04 5806 Rev 6) 2012}

Member Enrollment and Physician Selection Form ^{(CT-10-255 4207 REV9) 2012}

Connecticut Health Benefits Waiver of Coverage^{(CT-03-756 6424 R5) 2012}

Connecticut Family Health Statement^{(CT-11-0038 6357 R5) 2012}

Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}

CT Premium Payments for Termed Employees^{(CT-09-608) 2012}

Employer Request for Premium Credit Form^{(CT-10-541) 2012}

Complete Kit ²⁰¹²

Oxford CT (Freedom Plan Laurel Select)

FNA Oxford CT Submission Requirements 2012

Connecticut Small Group Application^{(OHPCT GA S 311 1768 R15) 2012}

Connecticut Small Group Attachment A - OHP^{(OHPCT UG S 5/04 5806 Rev 6) 2012}

Member Enrollment and Physician Selection Form ^{(CT-10-255 4207 REV9) 2012}

Connecticut Health Benefits Waiver of Coverage^{(CT-03-756 6424 R5) 2012}

Connecticut Family Health Statement^{(CT-11-0038 6357 R5) 2012}

Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}

CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}

Employer Request for Premium Credit Form^{(CT-10-541) 2012}

Complete Kit ²⁰¹²

Oxford CT (HMO/Freedom Network)

FNA Oxford CT Submission Requirements 2012

Connecticut Small Group Application^{(OHPCT GA S 311 1768 R15) 2012}

Connecticut Small Group Attachment A - OHP ^{(OHPCT UG S 5/04 5806 Rev 6) 2012}

Member Enrollment and Physician Selection Form^{(CT-10-255 4207 REV9) 2012}

Connecticut Health Benefits Waiver of Coverage^{(CT-03-756 6424 R5) 2012}

Connecticut Family Health Statement ^{(CT-11-0038 6357 R5) 2012}

Dental Enrollment Form ^{(OHP DE 10/96 040 Rev R5) 2012}

CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}

Employer Request for Premium Credit Form ^{(CT-10-541) 2012}

Complete Kit ²⁰¹²

Oxford CT (HMO Select/Freedom Network)

FNA Oxford CT Submission Requirements 2012

Connecticut Small Group Application^{(OHPCT GA S 311 1768 R15) 2012}

Connecticut Small Group Attachment A - OHP ^{(OHPCT UG S 5/04 5806 Rev 6) 2012}

Member Enrollment and Physician Selection Form^{(CT-10-255 4207 REV9) 2012}

Connecticut Health Benefits Waiver of Coverage^{(CT-03-756 6424 R5) 2012}

Connecticut Family Health Statement^{(CT-11-0038 6357 R5) 2012}

Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}

CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}

Employer Request for Premium Credit Form ^{(CT-10-541) 2012}

Complete Kit²⁰¹²

Oxford CT (HMO Laurel)

FNA Oxford CT Submission Requirements 2012

Connecticut Small Group Application^{(OHPCT GA S 311 1768 R15) 2012}

Connecticut Small Group Attachment A - OHP^{(OHPCT UG S 5/04 5806 Rev 6) 2012}

Member Enrollment and Physician Selection Form^{(CT-10-255 4207 Rev9) 2012}

Connecticut Health Benefits Waiver of Coverage^{(CT-03-756 6424 R5) 2012}

Connecticut Family Health Statement ^{(CT-11-0038 6357 R5) 2012}

Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}

CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}

Employer Request for Premium Credit Form^{(CT-10-541) 2012}

Complete Kit²⁰¹²

Oxford CT (HMO Laurel Select)

FNA Oxford CT Submission Requirements 2012

Connecticut Small Group Application^{(OHPCT GA S 311 1768 R15) 2012}

Connecticut Small Group Attachment A - OHP^{(OHPCT UG S 5/04 5806 Rev 6) 2012}

Member Enrollment and Physician Selection Form ^{(CT-10-255 4207 Rev9) 2012}

Connecticut Health Benefits Waiver of Coverage ^{(CT-03-756 6424 R5) 2012}

Connecticut Family Health Statement^{(CT-11-0038 6357 R5) 2012}

Dental Enrollment Form^{(OHP DE 10/96 040 Rev R5) 2012}

CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}

Employer Request for Premium Credit Form^{(CT-10-541) 2012}

Complete Kit²⁰¹²

Oxford CT (MyPlan)

FNA Oxford CT Submission Requirements 2012

Connecticut Small Group Application - OHI (5121)^{(OHICT GA S 311 5121 R17) 2012}

Connecticut Member Enrollment Form - OHI ^{(CT-10-254 5123 Rev 9) 2012}

Connecticut Health Benefits Waiver of Coverage ^{(CT-03-756 6424 R5) 2012}

Connecticut Family Health Statement ^{(CT-11-0038 6357 R5) 2012}

Oxford MyPlan Health Reserve Account Group Application

Oxford MyPlan Check Drafting Authorization

Oxford MyPlan Claim Disbursement ACH Authorization Release

CT Premium Payments for Termed Employees^{(CT-09-608) 2012}

Employer Request for Premium Credit Form ^{(CT-10-541) 2012}

Kit ²⁰¹²

Oxford CT (Connecticut Blue Ribbon)

FNA Oxford CT Submission Requirements 2012

Connecticut Small Group Blue Ribbon Application ^{(OHICT GA BR S 508 4556 R6) 2012}

Connecticut Small Group Attachment A - OHP ^{(OHPCT UG S 5/04 5806 Rev 6) 2012}

CT Premium Payments for Termed Employees^{(CT-09-608) 2012}

Employer Request for Premium Credit Form ^{(CT-10-541) 2012}

Complete Kit ²⁰¹²

Oxford CT (HSA)

FNA Oxford CT Submission Requirements 2012

GROUP

Connecticut Large Group Application-OHI (5122) ^{(OHICT GA L 508 07/11 5122 R19) 2012}

HSA Bank Notification Form^{(06-327 7423 R4) 2012}

MEMBER

Account Holder Brochure^{(045-0136 9/04) 2012}

HSA Card Agreement - OptumHealth Bank ^{(12/07 OH-FSV-DM-21208-993) 2012}

HSA Privacy Notice - OptumHealth Bank^{(045-0132 11/07) 2012}

HSA Custodial and Deposit Agreement - OptumHealth Bank ^{(045-0131 11/07) 2012}

HSA Application - OptumHealth Bank^{(045-0130 11/07)}²⁰¹²

CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}

Employer Request for Premium Credit Form^{(CT-10-541) 2012}

Complete Kit ²⁰¹²

Oxford CT (USA)

FNA Oxford CT Submission Requirements 2012

Connecticut Small Group Application (1768) (in-area employees) ^{(OHPCT GA S 311 1768 R15) 2012}

Connecticut Small Group Application - OHI (5121) (out-of-area employees) ^{(OHICT GA S 311 5121 R17) 2012}

Member Enrollment and Physician Selection Form (in-area employees)^{(CT-10-255 4207 REV9) 2012}

Connecticut Member Enrollment Form - OHI (out-of-area employees) ^{(CT-10-254 5123 Rev 9) 2012}

CT Premium Payments for Termed Employees ^{(CT-09-608) 2012}

Employer Request for Premium Credit Form ^{(CT-10-541) 2012}

Complete Kit ²⁰¹²

United Healthcare -Large Group

FNA United HealthcareSubmission Requirements 2012

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FNA Large Group Underwriting Requirements ²⁰¹²

FNA Large Group Request for Quote ²⁰¹²

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