Oxford Health Plans > Brokers Resources > Forms

Forms

For your convenience, group and member enrollment forms and applications can be downloaded from this website. Search
by state, line of business, and product to locate a form or application.


SMALL BUSINESS: Group and Member Enrollment Forms

New York Small Group (1-50): Oxford Health Plans (NY), Inc. (OHP) Applies to the following product: Liberty HMO
New York Small Group (1-50): Oxford Health Insurance, Inc. (OHI) Applies to the following products: Freedom Plan PPO, Liberty Plan PPO, Liberty Plan Gated PPO, Liberty Plan Gated EPO, Oxford EPO, Oxford EPO HSA, Oxford PPO HSA, Primary Advantage
New York Small Group (1-50): Healthy New York Applies to the following product: Healthy New York
New Jersey Small Group (2-50): Oxford Health Plans (NJ), Inc. (OHP) Applies to the following product: Primary Advantage
New Jersey Small Group (2-50): Oxford Health Insurance, Inc. (OHI) Applies to the following products: Oxford PPO Flex, Oxford Gated EPO, Oxford EPO, Oxford EPO HSA
Connecticut Small Group (1-50): Oxford Health Plans (CT), Inc. (OHP) Applies to the following products: Oxford Non-Gated HMO, Oxford Non-Gated HMO HSA, Oxford HMO HSA, Primary Advantage
Connecticut Small Group (1-50): Oxford Health Insurance, Inc. (OHI) Applies to the following products: Freedom Plan PPO, Freedom Plan Value Option, Oxford HSA PPO, Oxford Smart HSA
Connecticut Blue Ribbon Applies to the following products: Connecticut Blue Ribbon


LARGE BUSINESS: Group and Member Enrollment Forms

New York Large Group Applies to the following products:
Freedom Plan
Freedom Plan Select
Freedom Plan Access
Freedom Plan Classic
Freedom Plan Direct
HMO Select/Freedom Network
HMO/Freedom Network
Liberty Plan
Liberty Plan Select
Liberty Plan Access
Liberty Plan Classic
Liberty Plan Direct
HMO Select/Liberty Network
HMO/Liberty Product
Oxford HSA
Oxford MyPlan
Oxford USA
New Jersey Large Group Applies to the following products:
Freedom Plan
Freedom Plan Access
Freedom Plan Classic
Freedom Plan Direct
HMO
Liberty Plan
Liberty Plan Access
Liberty Plan Classic
Liberty Plan Direct
HMO/Liberty Product
Oxford HSA
Oxford MyPlan
Oxford USA
Connecticut Large Group Applies to the following products:
Freedom Plan
Freedom Plan Select
Freedom Plan Access
Freedom Plan Classic
Freedom Plan Direct
Freedom Plan Value Option
HMO/Freedom Network
HMO Select/Freedom Network
Oxford HSA
Oxford MyPlan
Oxford USA


ALL SIZE BUSINESSES: Various Forms for All States

Addition/Termination Forms New York and Connecticut Small and Large Groups Member Enrollment/Change Request Form
New Jersey Small Group Member Enrollment/Change Request Form - OHI
New Jersey Small Group Member Enrollment/Change Request Form - OHP
New Jersey Large Group Member Enrollment/Change Request Form - OHI
New Jersey Large Group Member Enrollment/Change Request Form - OHP
Miscellaneous Forms (all states) Attestation
Broker of Record Letter Template
GEN Accidental Injury Form
Small Group Contact/Address/Name Change Form
Mail Order Form
OptumHealth Managed Infertility Treatment Form
Prior Carrier Deductible Form
Triad Extension of Care
Triad Initial Care Plan
Triad Voluntary Prior Approval Process Agreement
Orthonet Voluntary Prior Approval Process Agreement
Member Authorization Form for Designated Representative to Appeal a Determination
Dental Provider Change Form
Dental Provider Application
GEN Cobra Election Form
NJ Small HSA Group Certificate of Understanding.pdf
Claims Forms (all states) Exercise Facility Reimbursement Form
Health Insurance Claim Form (HCFA 1500)
Prescription Drug Reimbursement Claim Form
Oxford MyPlan Health Reserve Acccount Claim Form
Authorization Forms (all states) Authorization for Broker to Act as Benefit Administrator
HIPAA Member Authorization
OptumRx Authorization Form
Medicare Advantage and Part D Forms Walgreens Mail Service Registration & Prescription Order Form - Medicare Advantage Plan
Walgreens Mail Service Registration & Prescription Order Form - Medicare Advantage Part D Plans