Forms & Resources
Below you'll find forms and resources organized by line of business or service and plan year. 2023 documents will be posted as they become available. Some forms may only be available on our secure site. If you can't find the form you need or require further assistance, please contact us.
Wellness
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Pharmacy
View our pharmacy services.
Individual and Family
- Plan Information and Forms
2023 Enrollment Guide (PDF)
Account Change Form (PDF)
Cost Share and Plan Mapping Document (PDF)
Dental Plans Summary of Benefits (PDF)
Individual & Family Service Area Map (PDF)
KPIF Enrollment Application (PDF)
Pediatric Dental Attestation (PDF)
Pharmacy Mail-Order Flyer (PDF)
Producer KPIF Training Manual (PDF)
Proof of Qualifying Life Event Form (PDF)
Special Enrollment Guide (PDF)
- Plan Information and Forms
Access PPO FAQ (PDF)
Compare Your Options Plan Brochure (PDF)
Employee Enrollment and Change Form (PDF)
2023 Group Master Application (PDF)
2023 Health Plans for Small Business (PDF)
Small Group Census Template (XLS)
2023 Underwriting Guidelines (PDF)
2023 Virtual Plus B2B Highlights (PDF)
Virtual Plus Overview for Consumers (PDF)
Virtual Plus Plan Guide (PDF)
2023 Virtual Plus Service Area Map (PDF)
Administrative Guide (PDF)
Deductible & Out-of-Pocket Crediting Form (PDF)
Disclosure Document (PDF)
Employer Attestation (PDF)
Enrollment Guide (PDF)
New Prospect Brochure (PDF)
Quote Request (PDF)
Rating Areas (PDF)
- Plan Information and Forms
2023 Complete Suite Brochure (PDF)
Access PPO Network Flyer (PDF)
Access PPO Travel Flyer (PDF)
Census Template (XLS)
Core HMO Network Flyer (PDF)
Core HMO Travel Flyer (PDF)
Employee Enrollment and Change Form (PDF)
Group Master Application (PDF)
Health360 B2B Sales Sheet (PDF)
Health360 B2B Slide Deck (PDF)
Health360 B2C Benefit Summary (PDF)
Large Group Base Enrollment Guide (PDF)
Summit PPO Network Flyer (PDF)
Summit PPO Travel Flyer (PDF)
Virtual Complete FAQ (PDF)
Virtual Complete OE Flyer (PDF)
Virtual Complete Sell Sheet (PDF)
Virtual Plus 2023 Enrollment Guide (LG/SG) (PDF)
- Materials
Benefits at a Glance – North (PDF)
Benefits at a Glance – Puget Sound (PDF)
Benefits at a Glance – Spokane (PDF)
Enrollment Form (PDF)
Guide to Medicare (PDF)
Medicare Advantage HMO Optional Dental Benefits (PDF)
Medicare Advantage Quoting Tool and Online Application Guide (PDF)
OTC Wellness Benefit (PDF)
Plan Summary Worksheet (PDF)
Plans and Benefits North Booklet (PDF)
Plans and Benefits Puget Sound Booklet (PDF)
Plans and Benefits Spokane Booklet (PDF)
Pre-Enrollment Checklist (PDF)
Pre-Enrollment Kit Baseline Cover Letter (PDF)
Scope of Appointment Form (PDF)
Service Area Map (PDF)
Silver and Fit Flyer (PDF)
Star Rating Flyer (PDF)
Summary of Benefits – Basic (HMO) (PDF)
Summary of Benefits – Centennial and Columbia (HMO) (PDF)
Summary of Benefits – Harbor and Anchor (HMO) (PDF)
Small Group
Large Group
Medicare Advantage
Individual and Family
- Plan Information and Forms
2022 Account Change Form (PDF)
2022 Affidavit of Non-Tobacco Use (PDF)
2022 Enrollment Guide (PDF)
2022 Individual & Family Medicare Sales Contact Sheet (PDF)
2022 Individual & Family Service Area Map (PDF)
2022 KPIF Enrollment Application (PDF)
2022 Pediatric Dental Attestation (PDF)
2022 Producer Reference Guide for Individual & Family Plans (PDF)
2022 Proof of Qualifying Life Event Form (PDF)
2022 Special Enrollment Guide (PDF)
- Plan Information and Forms
2022 Enrollment Guide (PDF)
2022 Underwriting Guidelines (PDF)
Access PPO FAQ (PDF)
Administrative Guide (PDF)
Combo Notice of Declining Coverage and Waiver Form (PDF)
Compare Your Options Plan Brochure (PDF)
Deductible & Out-of-Pocket Crediting Form (PDF)
Disclosure Document (PDF)
Employee Enrollment and Change Form (PDF)
Employer Attestation (PDF)
Group Master Application (PDF)
Health Plans for Small Business (PDF)
Quote Request Form (PDF)
Small Group Census Template (XLS)
Small Group Rating Areas (PDF)
Virtual Plus 2022 Enrollment Guide (PDF)
Virtual Plus B2B Highlights (PDF)
- Plan Information and Forms
Access PPO Basic Upfront (PDF)
Access PPO Network Flyer (PDF)
Access PPO Travel Flyer (PDF)
Access PPO Upfront Benefits Summary (PDF)
Census Template (XLS)
Core HMO Network Flyer (PDF)
Core HMO Travel Flyer (PDF)
Employee Enrollment and Change Form (PDF)
Group Master Application Customize GMA for WACA Health Plan Form (PDF)
Health360 B2B Sales Sheet (PDF)
Health360 B2B Slide Deck (PDF)
Health360 B2C Benefit Summary (PDF)
HMO HealthPays HSA Benefits Grid (PDF)
LG Base Guide (PDF)
Service Area Map - Summit PPO (PDF)
Summit PPO B2B Plans (PDF)
Summit PPO B2C Benefit Summary (PDF)
Virtual Complete FAQ (B2B) (PDF)
Virtual Complete OE Flyer (B2C) (PDF)
Virtual Complete Sell Sheet (B2B) (PDF)
Virtual Plus 2022 Enrollment Guide (PDF)
Virtual Plus Highlights for Large Groups (PDF)
- Materials
5 Star SEP FAQ (PDF)
2022 Plans and Benefits North Booklet (PDF)
2022 Plans and Benefits Puget Sound Booklet (PDF)
2022 Plans and Benefits Spokane Booklet (PDF)
Enrollment Form (PDF)
Guide to Medicare (PDF)
KPIF and Medicare Sales Contact Sheet (PDF)
Medicare Advantage HMO Optional Dental Benefits (PDF)
Nondiscrimination/MLI Notice (PDF)
Over-the-Counter Wellness Benefit (PDF)
Plan Summary Worksheet (PDF)
Pre-Enrollment Checklist (PDF)
Pre-Enrollment Kit Baseline Cover Letter (PDF)
Scope of Appointment Form (PDF)
Service Area Map (PDF)
Silver&Fit Flyer (PDF)
Star Rating Flyer (PDF)
Summary of Benefits Basic (HMO) (PDF)
Summary of Benefits Centennial and Columbia (HMO) (PDF)
Summary of Benefits Harbor and Anchor (HMO) (PDF)
Small Group
Large Group
Medicare Advantage
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©2022 Kaiser Foundation Health Plan of Washington