Brown/Raybourn - Insurance and Employee Benefits Brokers & Consultants

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Welcome to our insurance forms center. Please browse our links below to find the form in which you are in need. If you do not have Adobe .pdf Reader, please click the adobe picture below to download it to your computer.

If you have any questions, or we are missing a form you need, we encourage you to contact us. For all forms and applications, please contact our office's claims department.

ANTHEM LARGE GROUP

  
All Forms
Quote Request Checklist 50+
Anthem Employer Questionnaire
Anthem Large Group Employer Application
Blue Access Large Group Quote Request

ANTHEM SMALL GROUP


Enrollment Forms
Anthem Enrollment Checklist
Anthem Employer Application
Anthem Enrollment Application 2-50
Anthem Helpful Hints
Anthem Electronic Funds Transfer Form
Anthem Deductible Credit Form
Anthem Missing Information Form


Miscellaneous
Anthem Participation Worksheet
Anthem Subscriber Termination Form
Anthem Employee Change Form
Anthem Transmittal Guide
Anthem Transmittal Form
Anthem Group Administration Manual
Anthem Underwriting Guide
Anthem RX Mail Order Employer Form
Anthem RX Mail Order Employee Form
Anthem Prescription Drug Claim Form
Anthem Medical Claim Form


Quote Request
OH Blue Access Quote Request 2-50 eff. 8/1/09
KY Anthem Blue Access Quote Request 2-50

ANTHEM BLUE CROSS BLUE SHIELD
INDIVIDUAL PLANS

  
Applications
Anthem Ohio Individual Application
Anthem Kentucky Individual Application
KY Blue Access Application Supplement

Brochures
OH Premiere Brochure
OH Smart Sense Brochure
KY Premiere Brochure
KY Smart Sense Brochure
OH Premiere Benefits Guide
KY Premiere Benefits Guide
OH Smart Sense Benefit Guide
KY Smart Sense Benefit Guide

Miscellaneous
KY Blue Access Benefit Summary
KY Request for Under Writing Opinion
KY & OH List Bill Permission
KY & OH List Bill Request
Medical Claim Form



Questionnaires
Abnormal Pap Smear
Alcohol & Drug
Arthritis
Asthma / Allergy
Attention Deficit Disorder
Colitis
Diabetes
Digestive
Ear
Endometriosis
Fibromyalgia
Gout
Heart Murmur
Hypertension
Kidney
Mental Health
Migraine
Seizure / Epilepsy
Spinal
Thyroid
Tumor
Ulcer

MEDICAL MUTUAL OF OHIO


Large Group
MMO 51+ Quote Check List
MMO Employer Risk Assessment Form


Sales and Benefit Brochures
MMO Benefit Grid
MMO Small Group Benefit Plans
MMO Administrative Kit


Small Group
MMO Enrollment Checklist
MMO Employer Application
MMO Employee Application 2-19
MMO Employee Application 20+
MMO Contracts
MMO Deductible Credit Form
MMO Affidavit - New Groups Only


MMO Miscellaneous
MMO Mail Order Rx Form
MMO Prescription Drug Form


Short Term
Short Term - Benefits
Short Term - 250
Short Term - 500
Short Term - 1000
Short Term - 1500

MEDICAL MUTUAL OF OHIO


MMO Supermed One
Application
Healthy Lifestyle Questionnaire
Brochure
Benefit Summary - 500
Benefit Summary - 1000
Benefit Summary - 1500
Benefit Summary - 2500
Benefit Summary - 5000
Value - 500
Value - 1000
Value - 1500
Dental
Vision
List Bill Employer Agreement
List Bill Employee Agreement


MMO Supermed One HSA
HSA Brochure
HSA - 1200
HSA - 2200
HSA - 2500
HSA - 3000
HSA - 4000
HSA - 5000

UnitedHealthCare


Ohio Applications
Employer Application
Employee Enrollment (Group Size: 2-9)
Employee Enrollment (Group Size: 10-50)

Kentucky Applications
Employer App (Group Size: 2-50)
Employer App (Group Size: 51+)
Employee App (Group Size: 2-9)
Employee App (Group Size: 10-50)
Employee App (Group Size: 51+)
Submission Process (Group Size: 2-50)
Fast Track Cover Sheet


UHC Misc
Direct Debit Authorization
Mail Order Rx Form
Prescription Drug Reimbursement
Request for Alternate Renewal

MEDBEN


Ohio MedBen
Employee Application (group size 2-49)
Employee Application (group size 50+)
Dental & Vision Application
Change Request Form
Employer Application


West Virginia MedBen
Employee Application (group size 2-49)
Employee Application (group size 50+)
Dental & Vision Application
Change Request Form
Employer Application
TMJ Waiver
Underwriting Guidelines
Split Solution Brochure


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