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Forms for Members with Individual or Family Plans | Form | Description | | 2009 Individual Plan Application | Use this form to apply for individual or family coverage that is not sponsored by your employer | | 2010 Individual Plan Application | Use this form to apply for individual or family coverage that is not sponsored by your employer | | 2009 Solicitud del empleado | Utilice este formulario para solicitar una cobertura individual o familiar que no esté patrocinada por su empleador | | Individual Reapplication Form | Only use this form to reapply for SelectHealth coverage if you are a current member.. | | 2009 Change Form | Use this form to make changes in personal data, marital status, additions or deletions of family members, coverage status, etc. | | 2010 Medical Change Form | Use this form to make changes in personal data, marital status, additions or deletions of family members, coverage status, etc. | | 2010 Dental Change Form | Use this form to make changes to your dental plan in personal data, marital status, additions or deletions of family members, coverage status, etc. | | 2009 Formulario de cambio | Utilice este formulario para realizar cambios a los datos personales, estado civil, altas o bajas de familiares, estado de la cobertura, etc. | | 2009 Kids Plan Application | Use this form to apply for a SelectHealth Kids Plan, which provides kids with the comprehensive coverage they need, at a price more affordable than other insurance alternatives. | | 2010 Kids Plan Application | Use this form to apply for a SelectHealth Kids Plan, which provides kids with the comprehensive coverage they need, at a price more affordable than other insurance alternatives. | | 2009 Kids Plan Application - Spanish | Use this form to apply for a SelectHealth Kids Plan, which provides kids with the comprehensive coverage they need, at a price more affordable than other insurance alternatives. | | 2009 Kids Change Form | Use this form to make changes in personal data, additions for deletions of family members, coverage status, etc. | | 2009 Kids Change Form-Spanish | Utilice este formulario para realizar cambios a los datos personales, estado civil, altas o bajas de familiares, estado de la cobertura, etc. | | HIPUtah Change Form | Use this form to make changes in personal data, marital status, additions for deletions of family members, coverage status, etc. | Forms for Members with Small Employer Plans (2-50 benefits-eligible employees) | Form | Description | | 2009 Employee Application | Your employees must complete this form to enroll on a plan sponsored by your business | | 2009 Solicitud del empleado - Empleadores | Debe completar este formulario para inscribirse a un plan patrocinado por su empleador | | Employee Application - NationCare | Use this form if you are an out-of-state employee to enroll on a NationCare plan | | Change Form-English | Use this form to make changes in personal data, marital status, additions or deletions of family members, coverage status, etc. | | Formulario de cambio | Utilice este formulario para realizar cambios a los datos personales, estado civil, altas o bajas de familiares, estado de la cobertura, etc. | | Change Form - NationCare | Use this form if you are an out-of-state employee to make changes in personal data, marital status, additions or deletions of family members, coverage status, etc. | | Waiver Form-English | Use this form to officially decline or waive the health coverage sponsored by your employer | | Formulario de renuncia a la cobertura | Utilice este formulario para rechazar o renunciar a la cobertura de salud patrocinada por su empleador | | Waiver Form - NationCare | Use this form if you are an out-of-state employee to officially decline or waive NationCare coverage | Forms for Members with Large Employer Plans (51 or more benefits-eligible employees) | Form | Description | | Utah Large Employer Enrollment Form-English | You must complete this form to enroll on a plan or transfer from your current plan | | Formulario de inscripción para el empleador de gran capital en Utah | Debe completar este formulario para inscribirse a un plan o cambiarse de su plan actual | | NationCare Large Employer Enrollment Form | If you are an out-of-state employee, complete and submit this form to enroll on a NationCare plan or to transfer from your current plan | | Idaho Large Employer Enrollment Form-English | As an Idaho-based employee, you must complete this form to enroll on a plan or transfer from your current plan | | Formulario de inscripción para el empleador de gran capital en Idaho | Si es un empleado con base en Idaho, debe completar este formulario para inscribirse a un plan o para cambiarse de su plan actual | | Change Form-English | Use this form to make changes in personal data, marital status, additions or deletions of family members, coverage status, etc. | | Formulario de cambio | Utilice este formulario para realizar cambios a los datos personales, estado civil, altas o bajas de familiares, estado de la cobertura, etc. | | Change Form - NationCare | Use this form if you are an out-of-state employee to make changes in personal data, marital status, additions or deletions of family members, coverage status, etc. | | Secondary Medical Coverage | Complete and submit this form when covered under more than one medical/pharmacy plan | | Secondary Medical Coverage - NationCare | Use this form if you are an out-of-state employee when covered under more than one medical/pharmacy plan | Disclosure Authorization Forms | Form | Description | | Authorization to Disclose Information - English | Use this form to release health information to another person (e.g. relative, friend, broker, etc.) they will also have access to your claims information | | Autorización para revelar la información médica | Utilice este formulario para permitir que otra persona (por ejemplo, un pariente, un amigo, un intermediario, etc.) tenga acceso a su información médica y de sus reclamos | | Authorization to Release Health Information for Care Management | Use this form to release health information to another person (family member, friend) for Care Management purposes | Prescription Drug and Pharmacy Forms | Form | Description | | Prescription Drug List-Alphabetical | This list displays covered drugs in alphabetical order | | Prescription Drug List-Categorical | This list displays covered drugs by pharmaceutical category (e.g., contraceptive, cholesterol, etc.) | | Medco By Mail Order Form | Use this form to request mail delivery of certain maintenance prescriptions | | Participating Pharmacies (does not include pharmacies with Select Value) | This is a list of pharmacies participating on the Select Med, Select Care, and Select Choice networks | | Select Value Participating Pharmacies | This is a list of local and national pharmacies participating on the Select Value network | | Prescription Reimbursement Form-English | Use this form to request reimbursement for prescription payments. Pharmacy receipts must be attached with this form | | Formulario para el reembolso de medicamentos recetados | Utilice este formulario para solicitar el reembolso del pago de los medicamentos recetados.Los recibos de la farmacia se deben anexar a este formulario | Complaint Resolution Forms | Form | Description | | Customer Relations Appeal Form - English | Use this form to appeal a denied claim or submit complaints regarding service or care | | Formulario de apelación ante Servicios al Cliente | Utilice este formulario para apelar por un reclamo denegado o para presentar una queja en relación al servicio o a la atención | Order Materials for Individuals and Families | Form | Description | | Order Materials Online | Use this link to order forms, brochures, directories, etc. |
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