Health Insurance Form Templates

This Form is used for requesting Medi-Cal coverage for additional family members in California. It is available in Korean.

This document is a form for individuals in California who want to add additional family members to their Medi-Cal coverage.

This form is used for providing supplemental information for express enrollment in Medi-Cal, Healthy Families, and Healthy Kids programs in California.

This form is used for reporting Medi-Cal status in California for individuals who speak Tagalog.

This form is used for reporting the status of Medi-Cal benefits in California for individuals who speak Farsi.

This form is used for providing proof of acceptable citizenship or identity documents for California residents of Hmong descent.

This Form is used for acknowledging the receipt of COBRA rights, which provide employees with the right to continue their health insurance coverage after leaving their job or experiencing certain life events.

This Form is used for making payroll deductions towards your HSA contributions at Missouri Western State University.

This Form is used for making Medicare claims in Australia.

This form is used for submitting an international claim to Bluecross Blueshield. It is used when you need to request reimbursement for medical expenses incurred outside the United States.

This Form is used for submitting hospital claims to Medicare and Medicaid. It includes information on the services provided and the charges associated with them.

This Form is used for appealing a provider's request to Bluecross Blueshield of Texas in the state of Texas.

This Form is used for requesting extended or transitional Medi-Cal benefits in the state of California.

This form is used to request that health benefit premiums be deducted from retirement payments under the Civil Service Retirement System or the Federal Employees Retirement System. It is an alternative to using form SF 2805.

This form is used for applying for electronic funds transfer for health insurance claims assessment in the state of Michigan.

This Form is used for employees in Colorado to elect or make decisions regarding their Catastrophic Health Insurance coverage.

This Form is used for consenting to bridge from Medi-Cal to Healthy Families in California.

This document tracks the issues encountered during the Minnesota Health Insurance Exchange Project. It helps to identify and resolve problems in the project's development and implementation.

Use this form to apply for certain health benefits program, shared by the Department of Veterans Affairs (VA) with eligible beneficiaries.

This document is used to affirm eligibility for TRICARE for Life benefits for veterans.

This Form is used for reporting withholdings and contributions for health benefits by enrollment code.

This Form is used for notifying the Office of Personnel Management (OPM) about any changes in your health benefits enrollment under the Federal Employees Health Benefits Program.

This form is used for certifying health insurance coverage for J-1 Exchange Visitor Program participants.

This document is a sample of a Health Insurance Grant Contract specific to Minnesota. It is used as an agreement between Mnsure and a grant recipient for the purpose of providing health insurance coverage.

This document is a guide that provides information on Medicare Special Needs Plans (SNPs). It explains what SNPs are and the benefits they offer for individuals with specific health needs. It also highlights the eligibility criteria and enrollment process for SNPs.

Medicare is a federal health insurance program in the United States that provides coverage to individuals who are 65 years or older, as well as certain younger individuals with disabilities.

Medicaid is a joint federal and state program in the United States that provides health coverage to low-income individuals and families, including pregnant women, children, and people with disabilities.

This form is used for employers in California to report their health insurance coverage provided to employees.

This Form is used for health care providers in Florida to submit health insurance claims. It provides instructions on how to accurately complete the form.

This Form is used for submitting health insurance claims related to work hardening and pain management programs in the state of Florida. It provides instructions on how to properly fill out the form and submit it to the appropriate insurance provider.

This type of document provides instructions for completing the CMS-1500 Health Insurance Claim Form specifically for Ambulatory Surgical Centers in Florida.

This document is used to provide an explanation of benefits for individuals in Florida. It outlines the details of the healthcare services received and the corresponding costs, insurance coverage, and any additional information.

This form is used for applying for disabled child benefits through Highmark Blue Cross Blue Shield in Delaware.

This Form is used for providing information about the small business health insurance deduction in the state of Alabama.

This Form is used for applying for health insurance coverage in California and obtaining an order for it.