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Forms

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Medical Forms
Forms pertaining to a Medical plan
Benefit Authorization Standard
Agent Benefit Authorization
Employer Benefit Authorization
Benefit Authorization HRA
Benefit Authorization HSA
Benefit Authorization Mix n Match
Benefit Authorization Basic PPO
Funding Options
Rollover - What to expect
High Deductible Dental Plans
Employer Application
Employee Application
Dental Guidelines
Billing, Administration, Commissions
Sample Plan Design - $250 deductible
Sample Plan Design - $500 deductible

100% Self-Funded Dental
Employer Application
Employee Application
Dental Guidelines
Billing, Administration, Commissions
Cobra and Section 125 Forms
BEN-E-LECT COBRA Services

COBRA Election Forms
(for employers with 20 or more employees)
Basic Hospital PPO Plan
Blue Cross High Deductible Plan
Blue Shield High Deductible Plan
$2500 - $5000 High Deductible Plan

Cal-COBRA Election Forms
(for employers with less than 20 employees)
Basic Hospital PPO Plan
Blue Cross High Deductible Plan
Blue Shield High Deductible Plan
$2500 - $5000 High Deductible Plan

Section 125 Forms
Master Application
Employee Enrollment (FSA)
Employee Enrollment (POP)
What is an FSA (Flexible Spending Account)?
Freedom Plans Dental
Rate Sheet
Brochure
Employer Application
Employee Enrollment
Freedom Plan Flyer

Sample Explanation of Benefits
Sample EOBs from different carriers
Aetna
BEN-E-LECT
Blue Cross 		Blue Shield
Health Net
Nationwide 		Pacificare

HIPAA
New HIPAA Certificate (7/1/2005)

Miscellaneous
Employer Packet
Billing Procedures for your Patient Generic
FAX EOB Letter
Funding Options
Important Reminders Generic
Installation Kit Request Form

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