Forms

My Advance Care Plan (Form)

My Advance Care Planning Guide

Authorization for Use or Disclosure of Medical Information (Designated Representative)

Authorization for Use or Disclosure of Medical Information - THIS FORM MUST BE USED BY HEALTH EQUITY MEMBERS ONLY

Authorization to Release/Obtain PHI

Revocation of Authorization Form

Personal Health Information (PHI) Restriction Form

Disabled Dependent Certification Form

Formulario de Certificación de Dependiente Discapacitado

BusinessEDGE® Enrollment Application 5-250 Member 2024

BusinessEDGE® Enrollment Application 5-250 Member 2024 (en Español)

Group Auto Debit Withdrawal BusinessEDGE

Small Group 10-150 BusinessEDGE Enrollment Application

BusinessEDGE® Medical Risk Form

Confidentiality Agreement and Portal User Profile Form

Coordination of Benefits - Employers

Commercial Member Complaint Packet

Commercial Member Appeals Packet

Self-Funded Appeal Packet

Out-of-Area Dependent Child Form — for members enrolled in the Out-of-Area Dependent Program

Out-of-Area Dependent Child Form — for members whose employer has purchased the Out-of-Area dependent rider

Mail Order Frequently Asked Questions

Mirena Eligibility Form

Mirena Order Form

Specialty Pharmacy FAQs (Proprium Pharmacy)

Commercial and Medicaid Member Reimbursement Form

Transitioning Care to Sentara Health Plans

Virginia Small Employer COBRA