Health Plan Templates

This document provides information to employees about the health benefits they are entitled to under COBRA.

This Form is used for notifying the Office of Personnel Management (OPM) about any changes in your health benefits enrollment under the Federal Employees Health Benefits Program.

This Form is used for coordinating insurance benefits for individuals in Delaware.

This form is used for enrolling in health benefits in the state of Delaware.

This document provides a summary of health benefits available to residents in California, including information about coverage, costs, and important plan details.

This Form is used for enrolling in a health benefits plan for active employees in California. It provides instructions on how to complete Form HBD-12.

This Form is used for individuals in Missouri to create a specialized care plan for their personal needs.

Use this document, otherwise known as the IRS Health Coverage Form, for submitting a report to the Internal Revenue Service (IRS) and to taxpayers about individuals with minimum essential coverage who are not liable for the individual shared responsibility payment.

This document was issued by the Internal Revenue Service (IRS), the Department of Labor (DOL), and the Pension Benefit Guaranty Corporation (PBGC). It is a formal instrument used by employers that manage the employee benefit program to inform the authorities about the qualifications of the plan, investments made to the plan, and financial details of the program.

This document provides a summary of health benefits offered in California. It outlines the different types of coverage available, as well as the costs and benefits associated with each plan. It is a useful resource for understanding the health insurance options in California.

This form is used for enrolling in medical and dental insurance coverage in Vermont.

This type of document is the Form MC355 Medi-Cal Request for Information used in California. It allows individuals to request information relating to their Medi-Cal benefits.

This document is a survey conducted by health insurance carriers in Delaware. It gathers information about the health insurance needs and preferences of individuals in the state.

This document is used for Point of Service (POS) in Illinois. It pertains to a healthcare plan that allows participants to choose their own doctors and specialists.

This Form is used for notifying Health Plan about foster care or child protection placement in Minnesota.

This form is used for communicating with managed care programs in Texas. It is used to provide information or request assistance related to healthcare services.

This document provides information about the new health insurance marketplace coverage options and how they may affect your current health coverage. It explains the benefits and enrollment process for these new options.

This document allows individuals to request the transfer of their Health Savings Account (HSA) funds and gives consent for the transfer in the state of Arkansas.

This document proves that an individual's previous insurance policy has ended.

This document outlines the self-insured employer's plan for managed care in South Dakota. It provides information on how employers can provide healthcare coverage to their employees through a managed care system.

This document provides instructions for completing the Rhode Island Medicaid Prior Authorization Form. It is used to request approval for specific medical services or treatments before they can be covered by Medicaid in Rhode Island.

This document is a filing worksheet specifically designed for dental and health plans in California. It helps with organizing and recording the necessary information required for filing purposes.

This document provides information about health coverage options available to employees in the state of New Mexico. It outlines the various plans and benefits offered and explains how employees can enroll and access these benefits.

This document is for accessing contact information for the Project Safety & Health Plan MSDS Sheets in New York.

This document provides information about health coverage options available through employment in Alabama. It includes details about the types of coverage, eligibility requirements, and how to enroll.

This Form is used for explaining the medical benefits provided under Wisconsin's F-01234 Form. It provides instructions on how to understand and utilize these benefits.

This document is an Asthma Action Plan specific to the Washington, D.C. area. It provides guidance on managing asthma symptoms and emergencies in the region.

This Form is used for submitting a prior authorization request for Cimzia medication in the state of Vermont.

This document provides a blank template for creating an individualized health plan for residents of Oklahoma. It helps individuals outline their specific health goals and personalized healthcare strategies.

This document provides a template for an individualized health plan specifically for tube feedings in Oklahoma. It outlines the necessary information and considerations for creating a personalized plan for individuals who require tube feeding.

This Form is used for creating an individualized health plan for trach care in the state of Oklahoma.

This type of document is an individualized health plan template specifically for individuals with seizures in the state of Oklahoma. It provides a framework for developing a personalized plan to manage and address the unique needs of individuals with this condition.

This document is used for requesting approval for a maximum unit override for healthcare services in the state of Mississippi. It allows healthcare providers to exceed the usual limits set by insurance companies for the number of units of a specific service that can be provided.