Forms

Employer Forms and Information

Contacts

Sales and Service Team Contacts

Information

	ATNE Worksheet
	Healthy Weight Wellness Challenge
	Medicare Part D Notice for Employers
	Products and Services Brochure
	Stress-Free Me Challenge
	Where to Go For Care - ES

Groups

	Form Name
	Alternate Application Authorization
	AR State Group Continuation Coverage Election Form
	Authorization for Automatic Payments - Groups
	Care Management Referral Form
	Change Form
	Coordination of Benefits Questionnaire
	Designation of Personal Representative
	Disabled Dependent Request for Extension of Coverage
	Group Application for Coverage
	Group Employee Application
	Group Employee Application - ES
	Medical Claim Form
	Medical Plan Selection Form
	Medical Plan Selection Form - ES
	Preventive Care Benefits
	Preventive Care Benefits - ES
	Product Selection Sold Rate Form
	Request for Personal Health Information
	Request for Quote - Employer Only
	Termination Form

Flexible Spending Account

	Form Name
	FSA Claim Form
	FSA Election Form with Grace Period
	FSA Election Form with Rollover Provision
	FSA Eligible/Ineligible/OTC Expenses
	FSA Medical Necessity Form
	FSA Program Information
	FSA Secondary Card Request
	FSA — Step by Step
	FSA Substantiation Form
	FSA Worksheet

Group Term Life

	Form Name
	Death Benefits Claim Packet
	Designation of Beneficiary Form
	How to File a Life Insurance Claim
	Group Life Insurance Claim Form
	Group Life Insurance Claim Packet

Broker Forms and Information

Contacts

Sales and Service Team Contacts

Information

	ATNE Worksheet
	Deductible and OOP Credit Information Flyer
	Products and Services Brochure
	Stress-Free Me Challenge
	Where to Go For Care - ES

Broker/Agent Forms

	Form Name
	Broker Appointment Packet — Vision
	Broker/Agent Commission Assignment Form
	Broker New Group Submission Checklist
	Direct Deposit Authorization Form – Brokers Only
	Product Selection Sold Rate Form
	Request for Quote – Brokers Only

Flexible Spending Account

	Form Name
	FSA Claim Form
	FSA Election Form with Grace Period
	FSA Election Form with Rollover Provision
	FSA Eligible/Ineligible/OTC Expenses
	FSA Medical Necessity Form
	FSA Program Information
	FSA Secondary Card Request
	FSA — Step by Step
	FSA Substantiation Form
	FSA Worksheet

Groups and Individual

	Form Name
	Alternate Application Authorization
	AR State Group Continuation Coverage Election Form
	Authorization for Automatic Payments - Groups
	Billing and Payment Authorization Form — IQChoice
	Care Management Referral Form
	Change Form
	Coordination of Benefits Questionnaire
	Designation of Personal Representative
	Disabled Dependent Request for Extension of Coverage
	Group Application for Coverage
	Group Employee Application
	Group Employee Application - ES
	HRA Claim Form
	Medical Claim Form
	Medical Plan Selection Form
	Medical Plan Selection Form - ES
	Preventive Care Benefits
	Preventive Care Benefits - ES
	Request for Personal Health Information
	Termination Form

Group Term Life

	Form Name
	Death Benefits Claim Packet
	Designation of Beneficiary Form
	How to File a Life Insurance Claim
	Group Life Insurance Claim Form
	Group Life Insurance Claim Packet

MediQ65

	Form Name
	MediQ65 Application for Coverage (to enroll in 2022 plans)
	MediQ65 Application for Coverage (to enroll in 2023 plans)
	MediQ65 Payment Authorization Form
	Notice of Replacement Questionnaire

Provider Forms and Information

Forms

	Form Name
	Arkansas Provider Data Change Form
	Care Management Referral Form
	Disabled Dependent Request for Extension of Coverage
	Open Negotiation Request Form and Supplemental Form
	Out-of-Network Authorization Request Form (for use by Network Providers only)
	Plan of Care Form - SAMPLE ONLY
	Pre-authorization Request Form
	Pre-authorization Request Form–Clinically Urgent
	Predetermination Request Form
	Provider Appeal Form
	Provider Portal Administrator and User Access Forms
	Provider/Practice Change Form
	Provider/Practice Termination Form
	Request for Psychological Testing Form
	Request for Reconsideration Form
	Skilled Nursing Facility & Acute Rehabilitation Facility Fax Assessment Form

Information

	Form Name
	CPT® Category II Codes
	In-Network Lab Providers
	NIA Provider Quick Reference Guide
	NIA Utilization Review Matrix
	NIA Frequently Asked Questions
	Pre-Authorization and Concurrent Review Guidelines
	Preventive Care Benefits
	Prior Authorization Statistics
	Primary Care Quality Program
	Provider Claim Tips
	Provider Quick Reference Guide
	Provider Relations Territory Map
	Telehealth and Virtual Services Guide