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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.

2018 New York Small Group (1-100) Annual Certification Form (OHI)


SMALL BUSINESS: Group and Member Enrollment Forms

New York Small Group (1-100): Oxford Health Insurance, Inc. (OHI) Applies to the following products: PPO, PPO HSA, EPO, EPO HSA
New York Small Group (1-50): Healthy New York Applies to the following product: Healthy New York
New Jersey Small Group (1-50): Oxford Health Plans (NJ), Inc. (OHP) Applies to the following products: HMO
New Jersey Small Group (1-50): Oxford Health Insurance, Inc. (OHI) Applies to the following products: PPO, PPO HSA, EPO, EPO HSA
Connecticut Small Group (1-50): Oxford Health Plans (CT), Inc. (OHP) Applies to the following products: HMO, HMO HSA
Connecticut Small Group (1-50): Oxford Health Insurance, Inc. (OHI) Applies to the following products: PPO, PPO HSA


LARGE BUSINESS: Group and Member Enrollment Forms

New York Large Group (100+): Oxford Health Insurance, Inc. (OHI) Applies to the following products: Freedom Plan Classic/Liberty Plan Classic, Freedom Plan Access/Liberty Plan Access, Oxford Ease (Freedom & Liberty), Oxford Exclusive Plan (Freedom/Liberty/Metro), Oxford HSA Exclusive (Freedom & Metro), Primary Advantage (Freedom/Liberty/Metro)
New Jersey Large Group (51+): Oxford Health Plans (NJ), Inc. (OHP) Applies to the following products: Freedom Plan, Liberty Plan Primary Advantage (Freedom & Liberty)
New Jersey Large Group (51+): Oxford Health Insurance, Inc. (OHI) Applies to the following products: Freedom Plan Classic/Liberty Plan Classic, Freedom Plan Access/Liberty Plan Access, Freedom Plan Direct/Liberty Plan Direct, Oxford HSA Direct (Freedom/Liberty), Oxford Exclusive Plan (Liberty), Oxford EPO (Garden State), Oxford EPO HSA (Garden State), Primary Advantage (Garden State), NJ Public Sector (Freedom/Liberty)
Connecticut Large Group (51+): Oxford Health Plans (CT), Inc. (OHP) Applies to the following products: Freedom Plan, Freedom Plan Select, HMO, HMO HSA, HMO Select, Primary Advantage
Connecticut Large Group (51+): Oxford Health Insurance, Inc. (OHI) Applies to the following products: Freedom Plan Classic, Freedom Plan Access, Freedom Plan Direct, Freedom Plan Value Option, Oxford HSA Direct


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) Broker of Record Letter Template
Dental Provider Application
Dental Provider Change Form
Disability Questionnaire
GEN Accidental Injury Form
GEN Cobra Election Form
Invoice Guide for Employers Using oxfordhealth.com
Mail Order Form
Member Authorization Form for Designated Representative to Appeal a Determination
OptumHealth Managed Infertility Treatment Form
NJ Small HSA Group Certificate of Understanding
NY UnitedHealthcare Ancillary Spreadsheet
NY UnitedHealthcare Specialty Employer 2-99 Application
Orthonet Voluntary Prior Approval Process Agreement
Premium Payments by Scheduled Direct Debit
Deductible Form
Oxford New Jersey Prior Carrier Deductible Protocol
Small Group Contact/Address/Name Change Form
Triad Extension of Care
Triad Initial Care Plan
Triad Voluntary Prior Approval Process Agreement
CT & NJ Member Advance Notice Form for Involvement of Nonpar Provider
Claims Forms (all states) Sweat Equity Claim Form
Sweat Equity Claim Form(Spanish)
Sweat Equity Waiver
Sweat Equity Waiver(Spanish)
Health Insurance Claim Form (HCFA 1500)
Prescription Drug Reimbursement Claim Form
Prescription Drug Reimbursement Claim Form (Spanish)
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