Legal And Forms

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Atlanta Legal and Forms

2017 Individual Summary of Benefits and Coverage

Here are our official SBC's for Individual plans
Care Gold (2017)
Care Silver II (2017)
Care Silver I (2017)
Care Silver Copay (2017)
Care Bronze (2017)
Care Bronze Copay (2017)

2017 Individual Policy

Here is a sample of our individual policy document.
Georgia Individual Off-Exchange Policy (2017)

2017 Small Business Summary of Benefits and Coverage

Here are our official SBCs for business plans.
Care Gold (2017)
Care Silver II (2017)
Care Silver I (2017)
Care Silver Copay (2017)
Care Bronze (2017)
Care Bronze Copay (2017)

2017 Prescription Drug List

Georgia Prescription Drug List (2017)

2017 Business Certificates of Coverage

Here are samples of our certificates of coverage.
Georgia Small Business Certificate of Coverage (2017)
Georgia Large Business Certificate of Coverage (2017)

2017 Legal Notices and Policies

Claims Payment Policy Information Georgia (2017)
Electronic Delivery Consent Notice (2017)
Linking Policy (2017)
Member Rights and Responsibilities (2017)
Mobile Terms and Conditions (2017)
Overview of Producer Compensation (2017)
Preventive Care (2017)

2016 and 2017 Member Forms

Disabled Dependent Certification Form
Coordination of Benefits Form
HIPAA Authorization for Release of Personal Health Information (PHI)
Member Change Form
Transition of Care, Continuity of Care Application
Optum Rx Claim Form
Prior Authorization Form
Member Claim Form
Benefit Review and Complaint Form
Vision Plan Out of Network Claim Form
Appointment of Personal Representative for Appeals
Dental ADA Claim Form

2016 Individual Summary of Benefits and Coverage

Here are our official SBC's for Individual plans
Care Gold II (2016)
Care Gold I (2016)
Care Silver II (2016)
Care Silver I (2016)
Care Bronze (2016)

2016 Small Business Summary of Benefits and Coverage

Here are our official SBCs for business plans.
Care Platinum II (2016)
Care Platinum I (2016)
Care Gold II (2016)
Care Gold I (2016)
Care Silver II (2016)
Care Silver I (2016)
Care Bronze (2016)

Chicago Legal and Forms

2017 Individual Summary of Benefits and Coverage

Here are our official SBC's for Individual plans.
Care Gold (2017)
Care Silver II (2017)
Care Silver I (2017)
Care Silver Copay (2017)
Care Bronze (2017)
Care Bronze Copay (2017)

2017 Individual Policy

Here is a sample of our individual policy document.
Illinois Individual Off-Exchange Policy (2017)

2017 Small Business Summary of Benefits and Coverage

Here are our official SBCs for business plans.
Care Gold (2017)
Care Silver II (2017)
Care Silver I (2017)
Care Silver Copay (2017)
Care Bronze (2017)
Care Bronze Copay (2017)

2017 Prescription Drug List

Illinois Prescription Drug List (2017)

2017 Business Certificates of Coverage

Illinois Small Business Certificate of Coverage (2017)
Illinois Large Business Certificate of Coverage (2017)

2017 Legal Notices and Policies

Claims Payment Policy Information Illinois (2017)
Electronic Delivery Consent Notice (2017)
Linking Policy (2017)
Member Rights and Responsibilities (2017)
Mobile Terms and Conditions (2017)
Overview of Producer Compensation (2017)
Preventive Care (2017)

2016 and 2017 Member Forms

Disabled Dependent Certification Form
Coordination of Benefits Form
HIPAA Authorization for Release of Personal Health Information (PHI)
Member Change Form
Transition of Care, Continuity of Care Application
Optum Rx Claim Form
Prior Authorization Form
Member Claim Form
Benefit Review and Complaint Form
Vision Plan Out of Network Claim Form
Appointment of Personal Representative for Appeals
Dental ADA Claim Form

2016 Individual Summary of Benefits and Coverage

Here are our official SBC's for Individual plans.
Care Gold II (2016)
Care Gold I (2016)
Care Silver II (2016)
Care Silver I (2016)
Care Bronze (2016)

2016 Small Business Summary of Benefits and Coverage

Here are our official SBCs for business plans.
Care Platinum II (2016)
Care Platinum I (2016)
Care Gold II (2016)
Care Gold I (2016)
Care Silver II (2016)
Care Silver I (2016)
Care Bronze (2016)