BROKER FORMS & RESOURCES CLIENT FORMS & RESOURCES PLANS & THE MARKETPLACE APPPOINTMENT FORMS BROKER HOTLINE 888.870.4717 CLIENT FORMS & RESOURCES GeneralEnrollPaymentRx Member Change Form Appeals Process COB Verification Form Authorization to Release PHI Form Religious Employer Exemption Certification CHIP Model Notice Prior Authorization Information Prior Authorization Form Prior Authorization Information Provider Referral Form Individual Enrollment Small Group – Employee Small Group – Employer Credit Card Authorization – Individual Credit Card Authorization – Employer ACH/EFT Form – Individual ACH/EFT Form – Employer Premium Payment Information Formulary Prescription Drug Claim Prescription Mail Order Form QUICK LINKS Our Plans Service Area Become a Broker Broker Support Team Prescriptions Broker Portal APPOINTMENT FORMS Agency FormsBroker Forms Agency Appointment Packet Addendum to Broker Agreement for Web Brokers Broker Appointment Packet Addendum to Broker Agreement for Web Brokers
