MMA HEALTH FORMS
Addendum - Use With 2050015 [OH] - 2030445
Addendum to Health Insurance Application [CO] - 985182
Application - Employee - 100 or More [IA-IL-NE] - 2060164
Application - Employee - 100 or More [IN-VA] - 2050373
Application - Employee - 100 or More [KS] - 2060101
Application - Employee - 100 or More [MI] - 2060399
Application - Employee - 100 or More [OH] - 2060060
Application - Employee - 100 or More [PA] - 2060403
Application - Employee - 14 or Less [IA-IL-NE] - 2060162
Application - Employee - 14 or Less [IN-VA] - 2050375
Application - Employee - 14 or Less [KS] - 2060099
Application - Employee - 14 or Less [MI] - 2060397
Application - Employee - 14 or Less [OH] - 2060058
Application - Employee - 14 or Less [PA] - 2060401
Application - Employee - 15-99 [IA-IL-NE] - 2060163
Application - Employee - 15-99 [IN-VA] - 2050374
Application - Employee - 15-99 [KS] - 2060100
Application - Employee - 15-99 [MI] - 2060398
Application - Employee - 15-99 [OH] - 2060059
Application - Employee - 15-99 [PA] - 2060402
Application - Employee - Spanish 100 or More [IN] - 2060393
Application - Employee - Spanish 14 or Less [IN] - 2060391
Application - Employee - Spanish 15-99 [IN] - 2060392
Application - Employer [IA-NE] - 2060244
Application - Employer [IL] - 2060165
Application - Employer [IN-VA] - 2050372
Application - Employer [KS] - 2060098
Application - Employer [MI] - 2060396
Application - Employer [OH] - 2060061
Application - Employer [PA] - 2060400
Application CMP [AZ-ID-OR] - 2000596
Application for HSA [Multi-State] - 2070094
Application IA Basic and Standard [IA] - 2020294
Application Medsup Plans A - B - C - L [DE] - 2060286
Application Medsup Plans A - C [MI] - 2050321
Application Medsup Plans E - F - L [MI] - 2050322
Application Medsup Plans E - F [DE] - 2060287
Application Medsup [FL] - 2060510
Application Medsup [MD] - 2060511
Application Medsup [MT] - 2070500
Application Medsup [Multi-State] - 2050230
Application Medsup [Multi-State] - 2070499
Application Medsup [NE] - 2070654
Application Medsup [PA] - 2080000
Application Medsup [VA] - 2070502
Application SNEP Conversion [IA-IL-IN-MI-OH-NE] - 2050015
Application SNEP Conversion [KS] - 2050108
Application SNEP Conversion [PA] - 2050014
Application TeamCare Vantage [CO-IL-IN-NE-OH-MI-MD-OK] - 2070560
Application TeamCare Vantage [IA] - 2080033
Application TeamCare Vantage [KS] - 2080016
Application TeamCare Vantage [MT] - 2070810
Application TeamCare Vantage [PA] - 2070811
Application TeamCare Vantage [SD] - 2080032
Application TeamCare Vantage [VA] - 2070809
Authorization for Electronic Funds Transfer [Multi-State] - 2070391
Authorization to Release Protected Health Information [IA-IL-IN-KS-MI-NE-OH-PA-VA] - 2070287
Authorization to Release Protected Health Information [Multi-State] - 2030182
Authorization to Release Protected Health Information [VA] - 2040288
Beneficiary Change for HSA [Multi-State] - 2040195
Cancellation Request [Multi-State] - 2080117
Cancellation-Qualifying event for COBRA [Multi-State] - 2080321
Certification of Health Condition [Multi-State] - 990080
Continuation of Coverage [Multi-State] - 2080118
Contribution for MSA or HSA Individual [Multi-State] - 2050018
Delivery Receipt [SD] - 2030394
Dependent Eligibility Form [Multi-State] - 2070641
Direct Reimbursement Permission for HRA [Multi-State] - 2020464
Direct Transfer of MSA or HSA Funds [Multi-State] - 2070093
Disclosure Statement [DE] - 2060472
Discount Drug Card Agreement [KS] - 2050537
Disenrollment Form [Multi-State] - 2070298
Distribution Requests for HSA [Multi-State] - 2070271
Eligibility for Guaranteed Issue [CA-KS] - 980307
Eligibility Worksheet for HSA [Multi-State] - 2040572
Eligible Medical Expenses for HSAs [Multi-State] - 2040187
Employee Selection Within Group Health Insurance - HSA - PPO [Multi-State] - 2040248
Employees worksheet for SNEP [Multi-State] - 2040458
Employer - Group Contributions HSA [Multi-State] - 2030558
Employer Enrollment in HRA [Multi-State] - 2030372
Enrollment and Underwriting Disclosure - 2080358
Enrollment and Underwriting Disclosure [Multi-State] - 2070564
Event Registration [Multi-State] - 2070446
Fax Cover Sheet and Instructions for Enrollment Application [Multi-State] - 2070734
FlexChoice Employer Questionnaire [Multi-State] - 2040406
Getting the Most From Your Health Plan [Multi-State] - 2010241
Health Plan Discription HSA [CO] - 2085007
Health Plan Discription Indemnity [CO] - 2085006
Health Privacy Notice [Multi-State] - 2020140
How to File a Complaint [CA] - 2050471
HSA Disclosure Statement and Custodial Agreement [Multi-State] - 2050343
Important Consumer Notice [KS] - 2070085
Investment Choice HSA [Multi-State] - 2070812
Lead Follow-Up Report - 2080179
Limited Waiver of Guaranteed Issue [AZ-CA-MT-OR] - 970411
Limited Waiver of Guaranteed Issue [KS] - 2010450
Medical History [IA-IL-MI-NE-OH-PA] - 2010264
Medical History [IN-KS-VA] - 2010374
MedSup Outline of Coverage (150-152) [PA] - 2075263
MedSup Outline of Coverage (153-167) [PA] - 2075267
MedSup Outline of Coverage (168-169 177-188 195-196) [PA] - 2075268
MedSup Outline of Coverage (170-176) [PA] - 2075265
MedSup Outline of Coverage (189 193-194) [PA] - 2075264
MedSup Outline of Coverage (190-192 213) [PA] - 2075266
MedSup Outline of Coverage [AZ-ID-OR] - 2075307
MedSup Outline of Coverage [CA] - 2075259
MedSup Outline of Coverage [CO] - 2085048
MedSup Outline of Coverage [DE] - 2075318
MedSup Outline of Coverage [FL] - 2075319
MedSup Outline of Coverage [IA-IL-IN-OH-OK-SD] - 2085099
MedSup Outline of Coverage [KS] - 2085100
MedSup Outline of Coverage [MD] - 2075321
MedSup Outline of Coverage [MI] - 2075320
MedSup Outline of Coverage [MT] - 2075262
MedSup Outline of Coverage [NE] - 2075310
MedSup Outline of Coverage [VA] - 2085116
MedSupp 2008 Rate Pages (150-152) [PA] - 2075263-2
MedSupp 2008 Rate Pages (153-167) [PA] - 2075267-2
MedSupp 2008 Rate Pages (168-169 177-188 195-196) [PA] - 2075268-2
MedSupp 2008 Rate Pages (170-176) [PA] - 2075265-2
MedSupp 2008 Rate Pages (189 193-194) [PA] - 2075264-2
MedSupp 2008 Rate Pages (190-192 213) [PA] - 2075266-2
MedSupp 2008 Rate Pages (201 220-223) [VA] - 2085084
MedSupp 2008 Rate Pages (224-227 229-232 238-246) [VA] - 2085085
MedSupp 2008 Rate Pages (228) [VA] - 2085087
MedSupp 2008 Rate Pages (233-237) [VA] - 2085086
MedSupp 2008 Rate Pages (430-433 - 437-439 - 448-458) [OH] - 2085077
MedSupp 2008 Rate Pages (434 - 435) [OH] - 2085078
MedSupp 2008 Rate Pages (436 - 440-441 - 443-445) [OH] - 2085080
MedSupp 2008 Rate Pages (442 - 446 - 447) [OH] - 2085079
MedSupp 2008 Rate Pages (460-461 - 463 - 466 - 468-478) [IN] - 2085065
MedSupp 2008 Rate Pages (462 - 464) [IN] - 2085068
MedSupp 2008 Rate Pages (465) [IN] - 2085066
MedSupp 2008 Rate Pages (467) [IN] - 2085067
MedSupp 2008 Rate Pages (600-606) [IL] - 2085062
MedSupp 2008 Rate Pages (607-614 - 618-629) [IL] - 2085064
MedSupp 2008 Rate Pages (615-617) [IL] - 2085063
MedSupp 2008 Rate Pages (660-662) [KS] - 2085069
MedSupp 2008 Rate Pages (663-669 - 673 - 676-677 - 679) [KS] - 2085070
MedSupp 2008 Rate Pages (670-672 - 674-675 - 678) [KS] - 2085071
MedSupp 2008 Rate Pages (800-804) [CO] - 2085056
MedSupp 2008 Rate Pages (805-816) [CO] - 2085057
MedSupp 2008 Rate Pages (900-918) [CA] - 2085051
MedSupp 2008 Rate Pages (919-923 929-935 938-953 959-961) [CA] - 2085053
MedSupp 2008 Rate Pages (924-928) [CA] - 2085055
MedSupp 2008 Rate Pages (936 937) [CA] - 2085052
MedSupp 2008 Rate Pages (954-958) [CA] - 2085054
MedSupp 2008 Rate Pages [AZ] - 2085050
MedSupp 2008 Rate Pages [DE] - 2085058
MedSupp 2008 Rate Pages [FL] - 2075319-2
MedSupp 2008 Rate Pages [IA] - 2085060
MedSupp 2008 Rate Pages [ID] - 2085061
MedSupp 2008 Rate Pages [MD] - 2085072
MedSupp 2008 Rate Pages [MT] - 2085075
MedSupp 2008 Rate Pages [NE] - 2085076
MedSupp 2008 Rate Pages [OK] - 2085081
MedSupp 2008 Rate Pages [SD] - 2085083
Monthly Payment Plan for SNEP [Multi-State] - 2070195
Monthly Payment Plan [Multi-State] - 930479
Notice for the Life and Health Guarantee Association [CA] - 2070639
Notice for the Life and Health Guarantee Association [CO] - 2010406
Notice for the Life and Health Guarantee Association [ID] - 2070631
Notice for the Life and Health Guarantee Association [IL] - 2070632
Notice for the Life and Health Guarantee Association [IN] - 2070633
Notice for the Life and Health Guarantee Association [KS] - 2070634
Notice for the Life and Health Guarantee Association [MD] - 2070493
Notice for the Life and Health Guarantee Association [MI] - 2070635
Notice for the Life and Health Guarantee Association [OH] - 2070636
Notice for the Life and Health Guarantee Association [OK] - 2070637
Notice for the Life and Health Guarantee Association [SD] - 2030247
Notice for the Life and Health Guarantee Association [WA] - 2070638
Notice of Change in Health Plan Coverage - Transfer to Another Plan [Multi-State] - 2060232
Notice to Applicant Regarding Repl of Accident-Sickness Ins [CO] - 2020628
Notice to Applicant Regarding Replacement of MedSup or Medicare Advantage [Multi-State] - 2050231
Notice to Applicant Regarding Replacement of MedSup or Medicare Advantage [PA] - 2050483
Notice to Applicant Sr Ins Counseling [NE] - 985291
Outline of Coverage - HSA Coinsurance [PA] - 2075354
Outline of Coverage - PPO HSA Coinsurance [PA] - 2075353
Outline of Coverage State Mandated IA Basic Opt II [IA] - 975143
Outline of Coverage State Mandated IA Standard Opt II [IA] - 975144
Personal Report of Injury [Multi-State] - 2030072
Policy Checklist [IL] - 92109
Receipt [Multi-State] - 930480
Reimbursement Request for Medical Expense - HRA [Multi-State] - 2030128
Release of Account Information [Multi-State] - 2040043
Renewal Practices Disclosure [Multi-State] - 2070012
Request for Enrollment of Common Law Spouse [CO-IA-KS-MT] - 2060125
Request for Transfer from HSA to new HSA [Multi-State] - 2080233
Request to Extend Dependent Coverage (IN TCV - all CMP) [AZ-ID-OR] - 2080150
Request to Extend Dependent coverage [IN-VA] - 2080151
SNEP Conversion Plan Explanation [Multi-State] - 2040315
SNEP Employee Contributions HSA [Multi-State] - 2050017
SNEP Medical Questionnaire - ADD-ADHD [Multi-State] - 2040405
SNEP Medical Questionnaire - Arthritis [Multi-State] - 2040383
SNEP Medical Questionnaire - Back-Spine [IA-IN-MI-PA-VA] - 2060261
SNEP Medical Questionnaire - Back-Spine [IL-KS-NE-OH] - 2040384
SNEP Medical Questionnaire - Cancer-Tumor-Cyst [Multi-State] - 2040387
SNEP Medical Questionnaire - Cerebral Palsy [Multi-State] - 2040385
SNEP Medical Questionnaire - CPOD Emphysema [IA-IN-MI-PA-VA] - 2060262
SNEP Medical Questionnaire - CPOD Emphysema [IL-KS-NE-OH] - 2040386
SNEP Medical Questionnaire - Diabetes [IA-IN-MI-PA-VA] - 2060263
SNEP Medical Questionnaire - Diabetes [IL-KS-NE-OH] - 2040388
SNEP Medical Questionnaire - Drug and Alcohol [IA-IN-MI-PA-VA] - 2060264
SNEP Medical Questionnaire - Drug and Alcohol [IL-KS-NE-OH] - 2040389
SNEP Medical Questionnaire - Ear nose and Throat disorder [Multi-State] - 2040390
SNEP Medical Questionnaire - Epilepsy - Seizure [IA-IN-MI-PA-VA] - 2060265
SNEP Medical Questionnaire - Epilepsy - Seizure [IL-KS-NE-OH] - 2040391
SNEP Medical Questionnaire - Eye Disorder [Multi-State] - 2040392
SNEP Medical Questionnaire - Female Disorder [Multi-State] - 2040393
SNEP Medical Questionnaire - Gastrointestinal [Multi-State] - 2040394
SNEP Medical Questionnaire - Headache - Migraine [Multi-State] - 2040395
SNEP Medical Questionnaire - Heart [IA-IN-MI-PA-VA] - 2060266
SNEP Medical Questionnaire - Heart [IL-KS-NE-OH] - 2040396
SNEP Medical Questionnaire - Hernia [Multi-State] - 2040397
SNEP Medical Questionnaire - Kidney [Multi-State] - 2040398
SNEP Medical Questionnaire - Liver [Multi-State] - 2040399
SNEP Medical Questionnaire - Mental Health [IA-IN-MI-PA-VA] - 2060267
SNEP Medical Questionnaire - Mental Health [IL-KS-NE-OH] - 2040400
SNEP Medical Questionnaire - Neurological - Stroke [Multi-State] - 2040401
SNEP Medical Questionnaire - Pregnancy [Multi-State] - 2040402
SNEP Medical Questionnaire - Sexually Transmitted Diseases [Multi-State] - 2040403
SNEP Medical Questionnaire - Supplemental Medical [Multi-State] - 2040404
SNEP Medical Questionnaire - Thyroid Disorder [IA-IN-MI-PA-VA] - 2060260
SNEP Medical Questionnaire - Thyroid Disorder [IL-KS-NE-OH] - 2040331
SNEP Request for Quote 100 plus [Multi-State] - 2050402
SNEP Request for Quote 2-99 [Multi-State] - 2070105
Supplement to Health Insurance Application [CO] - 2025406
TCHP Outline of Coverage 70-30 PPO [IA] - 2045290
TCHP Outline of Coverage 80-20 PPO [IA] - 2045289
TCHP Outline of Coverage PPO [SD] - 2045291
TCV Disclosure Indemnity 50-50 [VA] - 2015203
TCV Disclosure PPO 50-50 [VA] - 2050051
TCV Disclosure PPO 80-20 [VA] - 2015087
TCV Disclosure [IA] - 2015078
TCV Disclosure [MI] - 2015319
TCV Disclosure [SD] - 2015416
TCV Outline of Coverage - Basic [SD] - 2025137
TCV Outline of Coverage - HSA 100-0 [IA] - 2015076
TCV Outline of Coverage - HSA 100-0 [IL] - 2015237
TCV Outline of Coverage - HSA 100-0 [PA] - 2005305
TCV Outline of Coverage - HSA 100-0 [SD] - 2015327
TCV Outline of Coverage - HSA 50-50 [IA] - 2045346
TCV Outline of Coverage - HSA 50-50 [IL] - 2045343
TCV Outline of Coverage - HSA 50-50 [PA] - 2045338
TCV Outline of Coverage - HSA 50-50 [SD] - 2045341
TCV Outline of Coverage - HSA [MT] - 2045129
TCV Outline of Coverage - Indemnity 50-50 [PA] - 2015270
TCV Outline of Coverage - Indemnity 80-20 [PA] - 2005285
TCV Outline of Coverage - Indemnity [IA] - 2015074
TCV Outline of Coverage - Indemnity [IL] - 2015236
TCV Outline of Coverage - Indemnity [MT] - 2045128
TCV Outline of Coverage - Indemnity [SD] - 2015326
TCV Outline of Coverage - PPO 50-50 [PA] - 2015271
TCV Outline of Coverage - PPO 80-20 [PA] - 2005304
TCV Outline of Coverage - PPO HSA 50-50 [PA] - 2045340
TCV Outline of Coverage - PPO [IA] - 2015075
TCV Outline of Coverage - PPO [IL] - 2015259
TCV Outline of Coverage - PPO [SD] - 2035243
TCV Outline of Coverage - PPO-HSA 100-0 [IA] - 2015077
TCV Outline of Coverage - PPO-HSA 100-0 [IL] - 2015260
TCV Outline of Coverage - PPO-HSA 100-0 [PA] - 2005306
TCV Outline of Coverage - PPO-HSA 100-0 [SD] - 2035244
TCV Outline of Coverage - PPO-HSA 50-50 [IA] - 2045345
TCV Outline of Coverage - PPO-HSA 50-50 [IL] - 2045344
TCV Outline of Coverage - PPO-HSA 50-50 [SD] - 2045342
TCV Outline of Coverage - Standard [SD] - 2025138
TCV Outline of Coverage - Uniform Plan [MT] - 2045130
TCV Transfer Application [Multi-State] - 2020388
Transfer Form Request to change Medsup Plan Coverage [Multi-State] - 2070042
Transfer of IRA Funds to an MMA HSA [Multi-State] - 2070107
Understanding New HSA Rules [Multi-State] - 2070117
Wellness Commitment [Multi-State] - 2030423
