Forms

Individual Member Forms

• Medical Change Form     
• Medical Change Form - Spanish
• Dental Change Form 
• Individual Reapplication  
• Individual Reapplication - Spanish
• Individual Plan Application 
• Individual Sales Packet 
• Transition Plan Application 
• Appeal Form
• Appeal Form - Spanish
• HealthEquity Authorization Form
• Payment Selection Form 

Small Employer Forms

• SE Change Form
• Formulario de cambio
• SE NationCare Change Form
• SE Employee Application
• Solicitud del empleado - Empleadores
• SE NationCare Application
• Waiver Form
• Utah Health Exchange Product Flyer
• Health Equity Authorization Form
• Health Equity Authorization Form - Spanish 

Large Employer

• Large Employer Enrollment
• Large Employer Enrollment (medical only)
• Large Employer Enrollment - Idaho 
• Formulario de inscripción para el empleador de gran capital en Utah
• Formulario de inscripción para el empleador de gran capital en Utah (Médicos sólo)
• NationCare LE Enrollment Form
• Change Form
• Formulario de cambio
• Change Form - NationCare
• Secondary Medical Coverage

HIPUtah and Federal-HIPUtah Forms

• HIPUtah and Federal-HIPUtah Application
• HIPUtah Change Form
• HIPUtah Participation Agreement
• Federal-HIPUtah Participation Agreement 
• HSA Enrollment and Authorization Form 
• HSA Contribution Form 

Disclosure Authorization Form

• General Authorization to Disclose Information
• Autorización para revelar la información médica
• Care Management Only - Authorization to Release Health Information

Pharmacy Forms

• Medco Pharmacy – Mail Order Form
• Medco Questionnaire
• Prescription Drug Reimbursement Form - English
• Formulario para el reembolso de medicamentos recetados

Application for Extension of Dependent Coverage

• Application for Extension of Dependent Coverage

Medical Claim Reimbursement Form

• Medical Claim Reimbursement Form