Forms & Resources
Below you'll find forms and resources organized by line of business or service and plan year. 2022 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
Access a range of tools to help your clients gain a competitive edge.
Pharmacy
View our pharmacy services.
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
- Plan Information and Forms
2021 Underwriting Guidelines (PDF)
Access PPO FAQ (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)
Elect PPO FAQ (PDF)
Elect PPO service area map (PDF)
Employee Enrollment and Change Form (PDF)
Group Master Application (PDF)
Health Plans for Small Business (PDF)
Open Enrollment Guide Access PPO Puget Sound Region (PDF)
Open Enrollment Guide Core Puget Sound Region (PDF)
Open Enrollment Guide Elect PPO (PDF)
Quote Request Form (PDF)
Small Group Census Template (XLS)
Small Group Rating Areas (PDF)
Virtual Plus 2021 B2B Highlights (PDF)
Virtual Plus 2021 Enrollment Guide (PDF)
- Plan Information and Forms
Access PPO Basic Upfront (PDF)
Access PPO Upfront Benefits Summary (PDF)
Employee Enrollment and Change Form (PDF)
Getting Care with Access PPO Plans (PDF)
Getting Care with Access PPO Puget Sound Plans (PDF)
Getting Care with Access PPO Spokane Plans (PDF)
Health360 B2B Sales Sheet (PDF)
Health360 B2B Slide Deck (PDF)
Health360 B2C Benefit Summary (PDF)
HMO HealthPays HSA Benefits Grid (PDF)
Service Area Map – Summit PPO (PDF)
Summit PPO B2B Plans (PDF)
Summit PPO B2C Benefit Summary (PDF)
Virtual Plus 2021 Enrollment Guide (PDF)
Virtual Plus Highlights for Large Groups (PDF)
2021 Account Change Form (PDF)
2021 Affidavit of Non-Tobacco Use (PDF)
2021 Enrollment Guide (PDF)
2021 Individual & Family Service Area Map (PDF)
2021 KPIF Enrollment Application (PDF)
2021 Pediatric Dental Attestation (PDF)
2021 Producer Reference Guide for Individual and Family Plans (PDF)
2021 Proof of Qualifying Life Event Form (PDF)
2021 Special Enrollment Guide (PDF)
Individual & Family and Medicare Sales Contact Sheet (PDF)
Small Group
Large Group
2021 Plans and Benefits North (PDF)
2021 Plans and Benefits Puget Sound (PDF)
2021 Plans and Benefits Spokane (PDF)
2021 Pre-enrollment kit baseline cover letter (PDF)
Enrollment Form (PDF)
KPIF and Medicare Sales Contact Sheet (PDF)
Medicare Advantage HMO Optional Dental Benefits (PDF)
Plan Summary Worksheet (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 (HMO) (PDF)
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© 2021 Kaiser Foundation Health Plan of Washington