Forms

Employer Forms and Information

Contacts

Sales and Service Team Contacts

Information

ATNE Worksheet (PDF)

Group Administration Guide (PDF)

Healthy Weight Wellness Challenge (PDF)

Medicare Part D Notice for Employers

Products and Services Brochure (PDF)

QualChoice National Network (PDF)

Stress-Free Me Challenge (PDF)

Where to Go For Care (PDF)

Where to Go For Care - ES (PDF)

Group

Alternate Application Authorization (PDF)

AR State Group Continuation Coverage Election Form (PDF)

Authorization for Automatic Payments - Groups (PDF)

Care Management Referral Form (PDF)

Change Form (PDF)

Coordination of Benefits Questionnaire (PDF)

Continuity of Care Form (PDF)

Designation of Personal Representative (PDF)

Disabled Dependent Request for Extension of Coverage (PDF)

Electronic Invoice Delivery Opt Out Form (PDF)

Group Application for Coverage (PDF)

Group Employee Application (PDF)

Group Employee Application - ES (PDF)

Medical Claim Form (PDF)

Medical Plan Selection Form (PDF)

Medical Plan Selection Form - ES (PDF)

Preventive Care Benefits (PDF)

Preventive Care Benefits - ES (PDF)

Product Selection & Sold Rate Form (PDF)

Request for Personal Health Information (PDF)

Request for Quote - Employer Only (PDF)

Termination Form (PDF)

Flexible Spending Account

FSA Claim Form (PDF)

FSA Election Form with Grace Period (PDF)

FSA Election Form with Rollover Provision (PDF)

FSA Eligible/Ineligible/OTC Expenses (PDF)

FSA Medical Necessity Form (PDF)

FSA Program Information (PDF)

FSA Secondary Card Request (PDF)

Take Steps to Save with an FSA Flyer (PDF)

FSA Substantiation Form (PDF)

FSA Worksheet (PDF)

Group Term Life

Designation of Beneficiary Form (PDF)

Group Life Insurance Claim Form (PDF)

Broker Forms and Information

Contacts

Sales and Service Team Contacts (PDF)

Information

ATNE Worksheet (PDF)

Deductible and OOP Credit Information Flyer (PDF)

Products and Services Brochure (PDF)

QualChoice National Network (PDF)

Stress-Free Me Challenge (PDF)

Where to Go For Care (PDF)

Where to Go For Care - ES (PDF)

Broker/Agent Forms

Broker New Group Submission Checklist (PDF)

Group Underwriting Guidelines (PDF)

Product Selection & Sold Rate Form (PDF)

Request for Quote – Brokers Only (PDF)

Flexible Spending Account

FSA Claim Form (PDF)

FSA Election Form with Grace Period (PDF)

FSA Election Form with Rollover Provision (PDF)

FSA Eligible/Ineligible/OTC Expenses (PDF)

FSA Medical Necessity Form (PDF)

FSA Program Information (PDF)

FSA Secondary Card Request (PDF)

Take Steps to Save with an FSA Flyer (PDF)

FSA Substantiation Form (PDF)

FSA Worksheet (PDF)

Group

Alternate Application Authorization (PDF)

AR State Group Continuation Coverage Election Form (PDF)

Authorization for Automatic Payments - Groups (PDF)

Care Management Referral Form (PDF)

Change Form (PDF)

Coordination of Benefits Questionnaire (PDF)

Continuity of Care Form (PDF)

Designation of Personal Representative (PDF)

Disabled Dependent Request for Extension of Coverage (PDF)

Electronic Invoice Delivery Opt Out Form (PDF)

Group Application for Coverage (PDF)

Group Employee Application (PDF)

Group Employee Application - ES (PDF)

HRA Claim Form (PDF)

Medical Claim Form (PDF)

Medical Plan Selection Form (PDF)

Medical Plan Selection Form - ES (PDF)

Preventive Care Benefits (PDF)

Preventive Care Benefits - ES (PDF)

Request for Personal Health Information (PDF)

Termination Form (PDF)

Group Term Life

Accelerated Life Insurance Claim Form (PDF)

Designation of Beneficiary Form (PDF)

Group Life Insurance Claim Form (PDF)

MediQ65

2026 MediQ65 Application for Coverage (PDF)

2026 Plan A (PDF)

2026 Plan F† (PDF)

2026 Plan G (PDF)

2026 Plan K (PDF)

2026 Plan N* (PDF)

2026 Plan F-HD† (PDF)

2026 Plan G-HD†† (PDF)

Designation of Personal Representative (PDF)

MediQ65 Dental Flyer and Claim Form (PDF)

MediQ65 Outline of Coverage (PDF)

MediQ65 Overview of Coverage (PDF)

Notice of Replacement Questionnaire (PDF)

Silver&Fit® Exercise & Healthy Aging Program (PDF)

^*Non-Guaranteed Issue Plan
^†Must be 65 before 1/1/2020
^††Must be 65 on or after 1/1/2020

Provider Forms and Information

Forms

Arkansas Provider Data Change Form (PDF)

Care Management Referral Form (PDF)

Continuity of Care Form (PDF)

Disabled Dependent Request for Extension of Coverage (PDF)

Open Negotiation Request Form and Supplemental Form (PDF)

Out-of-Network Authorization Request Form (for use by Network Providers only) (PDF)

Plan of Care Form - SAMPLE ONLY (PDF)

Pre-authorization Request Form (PDF)

Pre-authorization Request Form–Clinically Urgent (PDF)

Predetermination Request Form (PDF)

Provider Appeal Form (PDF)

Provider Exemption Status Appeal Form (PDF)

Provider Portal Administrator and User Access Forms (PDF)

Provider/Practice Change Form (PDF)

Provider/Practice Termination Form (PDF)

Request for Psychological Testing Form (PDF)

Request for Reconsideration Form (PDF)

Skilled Nursing Facility & Acute Rehabilitation Facility Fax Assessment Form (PDF)

Information

Clinical Practice Guidelines (PDF)

CPT® Category II Codes (PDF)

In-Network Lab Providers (PDF)

NIA Provider Quick Reference Guide (PDF)

NIA Utilization Review Matrix (PDF)

NIA Frequently Asked Questions (PDF)

Pre-Authorization and Concurrent Review Guidelines (PDF)

Preventive Care Benefits (PDF)

Prior Authorization Statistics

Provider Claim Tips (PDF)

Provider Quick Reference Guide (PDF)

Telehealth and Virtual Services Guide (PDF)