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RBG, CHICAGO - FORMS
UNITEDHEALTHCARE RELEASED DOWNLOAD
Employer Enrollment
1099 Independent Contractors Form
2/13/2014   Download
2016 Employer Application Groups 2-50
5/16/2016   Download
2016 Employer Application Groups 51-100

Description:
To be used for Gatekeeper underwriting as well as new business (pdf , 195k)

5/11/2016   Download
ACH Form
12/26/2014   Download
ATNE Form
7/31/2014   Download
Calendar Year & Policy Year Description
3/20/2014   Download
Common Ownership Form
2/13/2014   Download
Employer EServices Registration Form
4/24/2014   Download
Navigate PCP Election Form
2/13/2014   Download
Product and Benefit Selection Form 51 - 99 &

Description:
Standalone Ancillary (pdf , 74k)

9/22/2014   Download
Renewal Attestation Form
4/22/2016   Download
Select HRA Application Group Size 2-99
2/27/2016   Download
Employee Enrollment
2016 Employee Application 2-50
11/18/2015   Download
2016 Employee Application 51-99
2/27/2016   Download
Beneficiary Form
2/27/2016   Download
Domestic Partner Affidavit
10/24/2014   Download
Evidence of Insurability

Description:
To be completed by each employee when applying for Life, STD or LTD benefits over the guaranteed issue amount (pdf , 31k)

5/27/2014   Download
FSA Enrollment & Change Form
2/27/2016   Download
Medicare Status Change Form
10/24/2014   Download
PCP Election Form
10/24/2014   Download
Universal Online Application 2-50 (English)
2/22/2014   Download
Universal Online Application 2-50 (Spanish)
2/22/2014   Download
Administration
COC Comparison 2011 - 2014 Reform Compliant

Description:
ILLINOIS (pdf , 422k)
Version: m53504 10/13

2/13/2014   Download
Deductible Credit Guidelines
2/13/2014   Download
Temporary ID Card Instructions
2/13/2014   Download
Claims
Accelerated Benefits Claim Form
2/13/2014   Download
Dental Claim Form
2/13/2014   Download
HIPAA Release Form (PHI)
2/27/2016   Download
Life Claim Form
4/22/2014   Download
LTD Claim Form
2/13/2014   Download
Medical Claim Form
2/13/2014   Download
OptumRx Mail Order Form
2/13/2014   Download
OptumRx Prior Authorization
3/28/2016   Download
OptumRx Rx Reimbursement Form
4/17/2015   Download
Request for Portability of Critical Illness
2/13/2014   Download
STD Claim Form
2/13/2014   Download
Transition of Care
3/28/2016   Download
Vision Out of Network Claim Form
2/27/2016   Download