Forms and Applications
Advanced Directives
My Advance Care Plan (Form)
PDF, 500 KB
PDF, 500 KB
Agent of Record Form
Agent of Record - Change Request
PDF, 509 KB
PDF, 509 KB
Authorizations for Release of Medical Information
Broker Appointments
Broker Sign In
Coordination of Benefits
Electronic Commission Direct Deposit Registration Webpage
Individual & Family Plan Enrollment Applications
BusinessEDGE® Applications 5-250
BusinessEDGE Quoting Spreadsheet
XLSX, 57 KB
XLSX, 57 KB
Small Group Applications 1-50
Small Group Quoting Spreadsheet
XLSX, 100 KB
XLSX, 100 KB
Group Auto Debit Form
PDF, 518 KB
PDF, 518 KB
Mid-Market Applications 51-150 Eligible
2025 Mid Market Group Application
PDF, 279 KB
PDF, 279 KB
2024 Mid Market Group Application
PDF, 284 KB
PDF, 284 KB
Mid-Market Quoting Spreadsheet
XLSX, 59 KB
XLSX, 59 KB
GRx Census Template
XLSX, 8 KB
XLSX, 8 KB
Group Auto Debit Form
PDF, 518 KB
PDF, 518 KB
Open Enrollment Spreadsheet
Open Enrollment Spreadsheet
XLSX, 352 KB
XLSX, 352 KB
1099 Eligibility
HIPAA Agreement for PHI
HIPAA Agreement
PDF, 26 KB
PDF, 26 KB
Member Appeals Forms
Commercial Member Appeals Packet
PDF, 100 KB
PDF, 100 KB
Self-Funded Appeal Packet
PDF, 309 KB
PDF, 309 KB
Out-of-Area Dependent Child Forms
Pharmacy Reimbursement Form
Prescription Drug Claim Form
PDF, 112 KB
PDF, 112 KB
Transitional Care Forms
The American Recovery and Reinvestment Act of 2009 Forms
Virginia Small Employer COBRA
PDF, 70 KB
PDF, 70 KB