Forms: Activate^SM, Innova^SM, Engage^SM, & HSA Healthplan 2.0^SM

See other forms for Individual, Medicare, Regence Revive^SM, Regence Select, Regence Chamber Select and other plans.

• Group Master Applications
  • Groups 2-99 Employees
  • Groups 100+ Employees
• Spreadsheet Enrollment Procedure and Template (Groups 100+)



• Waiver Forms
  • Groups 2-50
  • Groups 51+
• Employee Applications
  • Small Employer Application (Groups 2-50) (PDF)
  • Application for Enrollment/Change (Groups 51-99) (PDF)
  • Application for Enrollment/Change (Groups 100+)
• Affidavit of Qualifying Incapacitated Dependent Eligibility
• Affidavit of Qualifying Domestic Partnership


• Dual Options & Guidelines

Effective dates 7/1/09 and beyond

• Activate/Innova/Engage Dual Option Matrix (Groups 25-50) (PDF)
• Innova/Engage Dual Option Matrix (Groups 15-50) (PDF)
• Innova/Engage/HSA 2.0 Dual Option Matrix (Groups 10-50) (PDF)
• Activate/Innova/Engage/HSA Healthplan 2.0 Dual Option Guidelines (Groups 51+) (PDF)
Effective dates 1/1/09 through 6/30/09
• Activate/Innova/Engage Dual Option Matrix (Groups 25-50) (PDF)
• Innova/Engage Dual Option Matrix (Groups 15-50) (PDF)
• Innova/Engage/HSA 2.0 Dual Option Matrix (Groups 10-50) (PDF)
• Activate/Innova/Engage/HSA Healthplan 2.0 Dual Option Guidelines (Groups 51+) (PDF)
• Group Proposal Request Form (Groups 2-50 & 51-99)
• Employee Certification (Groups 2-50) (PDF)
• Authorization to Disclose Protected Health Information (PDF)
• SurePay Form


• Employer Center & Online Enrollment
• Online Enrollment Set-Up Checklist (Groups 100+) (PDF)
• Employer Center Setup Form

To add access to Employer Center outside of initial enrollment or at a group’s renewal anniversary.

Spanish Language Forms / Formularios en Español

• Waiver Form (Group Size 2-50)/Formulario de renuncia (Tamaño del grupo 2 a 50)
• Waiver Form (Group Size 51-99)/Formulario de renuncia (Tamaño del grupo 51 a 99)
• Authorization to Disclose Health Information/Autorización para Divulgar Información Protegida de Salud
• Application for Enrollment/Change (PDF)