MMA HEALTH FORMS
Addendum - Use With 2050015 [OH] - 2030445
Addendum to Health Insurance Application [CO] - 985182
Application - Employee - 100 or More [IL] - 2060164
Application - Employee - 100 or More [KS] - 2060101
Application - Employee - 100 or More [VA] - 2050373
Application - Employee - 14 or Less [IL] - 2060162
Application - Employee - 14 or Less [KS] - 2060099
Application - Employee - 14 or Less [VA] - 2050375
Application - Employee - 15-99 [IL] - 2060163
Application - Employee - 15-99 [KS] - 2060100
Application - Employee - 15-99 [VA] - 2050374
Application - Employee - 2-99 [IA] - 2100135
Application - Employee - 2-99 [IN] - 2090360
Application - Employee - 2-99 [MI] - 2100089
Application - Employee - 2-99 [NE] - 2090570
Application - Employee - 2-99 [OH] - 2090554
Application - Employee - 2-99 [PA] - 2090630
Application - Employee - Experience related [IA-NE] - 2090569
Application - Employee - Experience related [IN] - 2090424
Application - Employee - Experience related [MI] - 2100090
Application - Employee - Experience related [OH] - 2090553
Application - Employee - Experience related [PA] - 2090631
Application - Employee - Spanish 2-99 [IN] - 2090492
Application - Employee - Spanish Experience-related [IN] - 2090493
Application - Employer [IA-NE] - 2090571
Application - Employer [IL] - 2060165
Application - Employer [IN-PA] - 2090428
Application - Employer [KS] - 2060098
Application - Employer [MI] - 2100091
Application - Employer [OH] - 2090555
Application - Employer [VA] - 2050372
Application CMP [AZ-ID-OR] - 2080092
Application IA Basic and Standard [IA] - 2020294
Application Medsup Plans A - C [MI] - 2090517
Application Medsup Plans F - L - N [MI] - 2090518
Application Medsup [AZ-ID] - 2090528
Application MedSup [CA] - 2100207
Application Medsup [CO] - 2090547
Application Medsup [DE] - 2090593
Application MedSup [FL] - 2090527
Application Medsup [IA-IL-IN-KS-NE-OH-OK-OR-SD] - 2090516
Application Medsup [MD] - 2090545
Application Medsup [MT] - 2090544
Application Medsup [PA] - 2090526
Application MedSup [VA] - 2090546
Application SNEP Conversion [IA-IL-IN-MI-OH] - 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 to Release Protected Health Info [CO-IL-IN-IA-KS-MD-MI-MT-NE-OH-OK-PA-SD] - 2030182
Authorization to Release Protected Health Information [IA-IL-IN-KS-MI-NE-OH-PA-VA] - 2070287
Authorization to Release Protected Health Information [VA] - 2040288
Cancellation Request [CO-IL-IN-IA-KS-MD-MI-MT-NE-OH-OK-PA-SD-VA] - 2090162
Cancellation-Qualifying event for COBRA [IL-IN-IA-KS-MI-NE-OH-PA-VA] -2090676
Certification for Premium Payment/Billing Notification - 2090443
Certification of Health Condition [CO-IL-IN-IA-KS-MD-MI-MT-NE-OH-OK-PA-SD-VA] - 990080
Continuation of Coverage [Multi-State] - 2090160
Delivery Receipt [SD] - 2010 - 2030394
Dependent Eligibility Form [IL-KS-MI-NE-OH] - 2090166
Dependent Eligilibity Form [CO] - 2080401
Dependent Eligilibity Form [IA] - 2080403
Dependent Eligilibity Form [IL-KS-MD-MI-NE-OH-OK-PA-SD-VA] - 2080370
Dependent Eligilibity Form [IN] - 2080402
Direct Reimbursement Permission for HRA [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2020464
Disclosure Statement [DE] - 2010 - 2060472
Disclosure Statement [IA] - 2105416
Discount Drug Card Agreement [KS] - 2010 - 2050537
Electronic Funds Transfer Re [AZ-CA-CO-DE-FL-ID-IL-IN-IA-KS-MD-MI-MT-NE-OH-OK-OR-PA-SD-VA] - 2090658
Eligibility for Guaranteed Issue [CA-KS] - 980307
Employee Selection Within Group Health Insurance - HSA - PPO [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2100181
Employees worksheet for SNEP [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040458
Employer Enrollment in HRA [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2030372
Enrollment and Underwriting Disclosure [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2070564
Enrollment for MMA's Courtesy Prescription Discount Program - 2090589
FlexChoice Employer Questionnaire [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040406
Getting the Most From Your Health Plan [CO-IL-IN-IA-KS-MD-MI-MT-NE-OH-OK-PA-SD-VA] - 2010241
Health Privacy Notice [CO-IL-IN-IA-KS-MD-MI-MT-NE-OH-OK-PA-SD-VA] - 2020140
How to File a Complaint [CA] - 2050471
Important Consumer Notice [KS] - 2010 - 2070085
Information Collection Sheet for Prescription Drug Coverage - 2090607
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
Medicare Part D Consulting Agreement - 2090732
Medicare Supplement Lead Intake Form - 2090806
MedSup Outline of Coverage for 2010 Plan [AZ-FL-ID] - 2105292
MedSup Outline of Coverage for 2010 Plan [CA] - 2105285
MedSup Outline of Coverage for 2010 Plan [CO] - 2105286
MedSup Outline of Coverage for 2010 Plan [DE] - 2105293
MedSup Outline of Coverage for 2010 Plan [FL] - 2105302
MedSup Outline of Coverage for 2010 Plan [IA] - 2105288
MedSup Outline of Coverage for 2010 Plan [IL-IN-MI-NE-OK-OR-SD] - 2105284
MedSup Outline of Coverage for 2010 Plan [KS] - 2105289
MedSup Outline of Coverage for 2010 Plan [MD] - 2105300
MedSup Outline of Coverage for 2010 Plan [MT] - 2105290
MedSup Outline of Coverage for 2010 Plan [OH] - 2105294
MedSup Outline of Coverage for 2010 Plan [PA] - 2105287
MedSup Outline of Coverage for 2010 Plan [VA] - 2105291
MedSupp Rate Pages for 2010 Plan [AZ] - 2105292 AZ-1
MedSupp Rate Pages for 2010 Plan [CA - 900-918] - 2105285 CA-1
MedSupp Rate Pages for 2010 Plan [CA - 919-923 929-935 938-953 959-961] - 2105285 CA-3
MedSupp Rate Pages for 2010 Plan [CA - 924-928] - 2105285 CA-5
MedSupp Rate Pages for 2010 Plan [CA - 936-937] - 2105285 CA-2
MedSupp Rate Pages for 2010 Plan [CA - 954-958] - 2105285 CA-4
MedSupp Rate Pages for 2010 Plan [CO - 800-804] - 2105286 CO-1
MedSupp Rate Pages for 2010 Plan [CO - 805-816] - 2105286 CO-2
MedSupp Rate Pages for 2010 Plan [DE] - 2105293 DE-1
MedSupp Rate Pages for 2010 Plan [FL] - 2105302 FL-1
MedSupp Rate Pages for 2010 Plan [IA] - 2105288 IA-1
MedSupp Rate Pages for 2010 Plan [ID] - 2105292 ID-1
MedSupp Rate Pages for 2010 Plan [IL - 600-606] - 2105284 IL-1
MedSupp Rate Pages for 2010 Plan [IL - 607-614, 618-629] - 2105284 IL-3
MedSupp Rate Pages for 2010 Plan [IL - 615-617] - 2105284 IL-2
MedSupp Rate Pages for 2010 Plan [IN - 460-461, 463, 466, 468-479] - 2105284 IN-1
MedSupp Rate Pages for 2010 Plan [IN - 462, 464] - 2105284 IN-4
MedSupp Rate Pages for 2010 Plan [IN - 465] - 2105284 IN-2
MedSupp Rate Pages for 2010 Plan [IN - 467] - 2105284 IN-3
MedSupp Rate Pages for 2010 Plan [KS - 660-662] - 2105289 KS-1
MedSupp Rate Pages for 2010 Plan [KS - 663-669, 673, 676-677, 679] - 2105289 KS-2
MedSupp Rate Pages for 2010 Plan [KS - 670-672, 674-675, 678] - 2105289 KS-3
MedSupp Rate Pages for 2010 Plan [MD] - 2105300 MD-1
MedSupp Rate Pages for 2010 Plan [MI - 480-483, 486-487] - 2105284 MI-1
MedSupp Rate Pages for 2010 Plan [MI - 484-485, 488-489, 492-495, 498-499] - 2105284 MI-4
MedSupp Rate Pages for 2010 Plan [MI - 490-491] - 2105284 MI-2
MedSupp Rate Pages for 2010 Plan [MI - 496-497] - 2105284 MI-3
MedSupp Rate Pages for 2010 Plan [MT] - 2105290 MT-1
MedSupp Rate Pages for 2010 Plan [NE] - 2105284 NE-1
MedSupp Rate Pages for 2010 Plan [OH - 430-433, 458] - 2105294 OH-1
MedSupp Rate Pages for 2010 Plan [OH - 434-435] - 2105294 OH-2
MedSupp Rate Pages for 2010 Plan [OH - 436, 440-441, 443-445] - 2105294 OH-4
MedSupp Rate Pages for 2010 Plan [OH - 437-439, 448-457] - 2105294 OH-5
MedSupp Rate Pages for 2010 Plan [OH - 442, 446-447] - 2105294 OH-3
MedSupp Rate Pages for 2010 Plan [OK] - 2105284 OK-1
MedSupp Rate Pages for 2010 Plan [OR] - 2105284 OR-1
MedSupp Rate Pages for 2010 Plan [PA - 150-152] - 2105287
MedSupp Rate Pages for 2010 Plan [PA - 153-167] - 2105287
MedSupp Rate Pages for 2010 Plan [PA - 168-169, 177-188, 195-196] - 2105287
MedSupp Rate Pages for 2010 Plan [PA - 170-176] - 2105287
MedSupp Rate Pages for 2010 Plan [PA - 189, 193-194] - 2105287
MedSupp Rate Pages for 2010 Plan [PA - 190-192, 213] - 2105287
MedSupp Rate Pages for 2010 Plan [SD] - 2105284 SD-1
MedSupp Rate Pages for 2010 Plan [VA - 201, 220-223] - 2105291 VA-1
MedSupp Rate Pages for 2010 Plan [VA - 224-227, 229-232, 238-246] - 2105291 VA-2
MedSupp Rate Pages for 2010 Plan [VA - 228] - 2105291 VA-4
MedSupp Rate Pages for 2010 Plan [VA - 233-237] - 2105291 VA-3
Monthly Payment Plan for SNEP [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2090973
Notice for the Life and Health Guarantee Association [CA] - 2070639
Notice for the Life and Health Guarantee Association [CO] - 2100351
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] - 2090879
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 [MT] - 2090938
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 [PA] - 2090939
Notice for the Life and Health Guarantee Association [SD] - 2100352
Notice for the Life and Health Guarantee Association [WA] - 2070638
Notice of Change in Health Plan [CO-IL-IN-IA-KS-MD-MI-MT-NE-OH-OK-PA-SD-VA] - 2060232
Notice Repl of MedSup/Medicare [AZ-CA-CO-DE-ID-IL-IN-IA-KS-MD-MI-MT-NE-OH-OK-OR-SD-VA] 2010- 2050231
Notice to Applicant Regarding Repl of Accident-Sickness Ins [CO] - 2020628
Notice to Applicant Regarding Replacement of MedSup or Medicare Advantage [PA] - 2010 - 2050483
Notice to Applicant Sr Ins Counseling [NE] - 2010 - 2105537
Notice: Telephone Medical Intervview May be Requested
Ohio Basic and Standard [OH] - 2090890
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 [CO-IL-IN-IA-KS-MD-MI-MT-NE-OH-OK-PA-SD-VA] - 2030072
Plan Description - Indemnity [CO] - 2095174
Plan Description - PPO QHDHP [CO] - 2095160
Plan Description - PPO [CO] - 2095159
Plan Description - QHDHP [CO] - 2095173
Policy Checklist [IL] - 2100411
Receipt [CO-IL-IN-IA-KS-MD-MI-MT-NE-OH-OK-PA-SD-VA] - 930480
Reimbursement Request for Medical Expense - HRA [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2030128
Request for Enrollment of Common Law Spouse [CO-IA-KS-MT] - 2060125
Request to Change Medsup Plan [AZ-CA-CO-DE-ID-IL-IN-IA-KS-MD-MI-MT-NE-OH-OK-OR-PA-SD-VA] - 2070042
Request to Extend Dependent Coverage (IN TCV - all CMP) [AZ-ID-OR] - 2080150
Request to Extend Dependent Coverage [IN-VA] - 2090972
Senior Lead Follow-Up Report - 2100516
ShareNet Dependent Eligibillity Form [IA] - 2090165
ShareNet Dependent Eligibillity Form [IN-VA] - 2090164
ShareNet Dependent Eligibillity Form [PA] - 2090448
ShareNet Employer Plan Change Form - 2090869
ShareNet Extended Dependent Eligibility Worksheet - 2090187
ShareNet Life Insurance Claim - 940424
ShareNet Weekly Income Claim - 2000410
SNEP Conversion Plan Explanation [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040315
SNEP Medical Questionnaire - ADD-ADHD [Multi-State] - 2040405
SNEP Medical Questionnaire - Arthritis [IL-IN-IA-KS-MI-OH-PA-VA] - 2040383
SNEP Medical Questionnaire - Arthritis [NE] - 2090895
SNEP Medical Questionnaire - Back-Spine [IA-IL-IN-KS-MI-NE-OH-PA-VA] - 2060261
SNEP Medical Questionnaire - Cancer-Tumor-Cyst [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040387
SNEP Medical Questionnaire - Cerebral Palsy [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040385
SNEP Medical Questionnaire - COPD Emphysema [IA-IL-IN-KS-MI-NE-OH-PA-VA] - 2060262
SNEP Medical Questionnaire - Diabetes [IA-IL-IN-KS-MI-NE-OH-PA-VA] - 2060263
SNEP Medical Questionnaire - Drug and Alcohol [IA-IL-IN-KS-MI-NE-OH-PA-VA] - 2060264
SNEP Medical Questionnaire - Ear nose and Throat disorder [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040390
SNEP Medical Questionnaire - Epilepsy - Seizure [IA-IL-IN-KS-MI-NE-OH-PA-VA] - 2060265
SNEP Medical Questionnaire - Eye Disorder [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040392
SNEP Medical Questionnaire - Female Disorder [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040393
SNEP Medical Questionnaire - Gastrointestinal [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040394
SNEP Medical Questionnaire - Headache - Migraine [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040395
SNEP Medical Questionnaire - Heart [IA-IL-IN-KS-MI-NE-OH-PA-VA] - 2060266
SNEP Medical Questionnaire - Hernia [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040397
SNEP Medical Questionnaire - Kidney [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040398
SNEP Medical Questionnaire - Liver [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040399
SNEP Medical Questionnaire - Mental Health [IA-IL-IN-KS-MI-NE-OH-PA-VA] - 2060267
SNEP Medical Questionnaire - Neurological - Stroke [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040401
SNEP Medical Questionnaire - Pregnancy [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040402
SNEP Medical Questionnaire - Sexually Transmitted Diseases [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040403
SNEP Medical Questionnaire - Supplemental Medical [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2040404
SNEP Medical Questionnaire - Thyroid Disorder [IA-IL-IN-KS-MI-NE-OH-PA-VA] - 2060260
SNEP Request for Quote 100 plus [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2050402
SNEP Request for Quote 2-99 [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2080625
SNEP VI Request for Quote 2-99 [IL-IN-IA-KS-MI-NE-OH-PA-VA] - 2100388
Social Security Number Verification - 2090599
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] - 2095054
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] - 2105335
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] - 2105334
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] - 2095055
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 [CO-IL-IN-IA-KS-MD-MI-MT-NE-OH-OK-PA-SD-VA] - 2020388
Wellness Commitment [CO-IL-IN-IA-KS-MD-MI-MT-NE-OH-OK-PA-SD-VA] - 2080472
Your Open Enrollment and Guaranteed Issue Rights - 2010 - 2060078
