Member Forms and Information

Appeals Rights & Requests

Form Name
Member Appeal Request Form
Right to Appeal Notice

Group & Individual

Form Name
Coordination of Benefits Questionnaire
Dependent Certification Form
Designation of Personal Representative
Disabled Dependent Request for Extension of Coverage
Medical Claim Form
Member Handbook
Preventive Care Benefits
Preventive Care Benefits - ES
PCP Selection or Change Form
Request for Personal Health Information
Transplant Travel and Lodging Expense Form
Billing and Payment Authorization Form — For Federally Facilitated Marketplace, Arkansas Works, CHI Retirees
Billing and Payment Authorization Form — IQChoice

Flexible Spending Account

Form Name
FSA Authorization Agreement for Direct Deposit
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
Designation of Beneficiary Form
Group Life Insurance Claim Form
Group Life Insurance Health Statement
Group Term Life Fact Sheet

QCARE Health Management Programs

Form Name
Diabetes Assessment Form
Hypertension Assessment Form
Maternal Health Appraisal Form
Maternity Notification Form

Catholic Health Initiatives (CHI) Members

Need another form? For help call Customer Service at 800.235.7111.

Form Name
Medical Appeal Request Form
Medical Claim Form

MediQ65

Form Name
MediQ65 2019 Application for Coverage
MediQ65 2019 Plan Change Request Form
MediQ65 2020 Plan Change Request Form (for individuals eligible for Medicare before January 1, 2020)
MediQ65 2020 Plan Change Request Form (for individuals eligible for Medicare on or after January 1, 2020)
MediQ65 Payment Authorization Form
Notice of Replacement Questionnaire

Employer Forms and Information

Contacts

Sales and Service Team Contacts
Individual Products Contact Sheet

Information

ATNE Worksheet
Healthy Weight Wellness Challenge
Stress-Free Me Challenge

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 2019
Group Employee Application (for large or small new groups and hires with effective date on or after January 1, 2019)
Group Application for Coverage 2020
Group Employee Application (for large or small new groups and hires with effective date on or after January 1, 2020)
Group Employee Application - ES (for large or small new groups and hires with effective date on or after January 1, 2020)
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 Authorization Agreement for Direct Deposit
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
Designation of Beneficiary Form
Group Life Insurance Claim Form
Group Life Insurance Health Statement
Group Term Life Fact Sheet

Broker Forms and Information

Contacts

Sales and Service Team Contacts
Individual Products Contact Sheet

Information

ATNE Worksheet
Healthy Weight Wellness Challenge
Stress-Free Me Challenge

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 (now writable)

Flexible Spending Account

Form Name
FSA Authorization Agreement for Direct Deposit
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
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 2019
Group Employee Application (for large or small new groups and hires with effective date on or after January 1, 2019)
Group Application for Coverage 2020
Group Employee Application (for large or small new groups and hires with effective date on or after January 1, 2020)
Group Employee Application - ES (for large or small new groups and hires with effective date on or after January 1, 2020)
Individual Marketplace 2019 Benefits-at-a-Glance
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
Billing and Payment Authorization Form — For Federally Facilitated Marketplace, Arkansas Works, CHI Retirees
Billing and Payment Authorization Form — IQChoice

Group Term Life

Form Name
Designation of Beneficiary Form
Group Life Insurance Claim Form
Group Life Insurance Health Statement
Group Term Life Fact Sheet

MediQ65

Form Name
MediQ65 2019 Application for Coverage
MediQ65 2019 Plan Change Request Form
MediQ65 2020 Plan Change Request Form (for individuals eligible for Medicare before January 1, 2020)
MediQ65 2020 Plan Change Request Form (for individuals eligible for Medicare on or after January 1, 2020)
MediQ65 Payment Authorization Form
Notice of Replacement Questionnaire