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NEW YORK SMALL GROUP (1-100): GROUP AND MEMBER ENROLLMENT FORMS

New York Small Group Enrollment Checklist

New York Small Group (1-100) Underwriting Requirements

New York Small Group (1-100) Tax Form Submissions Instruction Sheet

New York Authorization for Broker to Act as Benefits Administrator

New York New Plan Election Form

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

Employees Attestation


New York Small Group (1-100): Oxford Health Insurance (OHI)

Applies to 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 Application - OHI
Group Affirmation Letter
New York Member Enrollment Form - OHI
Dental Enrollment Form
New York Health Benefits Waiver of Coverage
New York Health Benefits Waiver of Coverage (Chinese)
New York Health Benefits Waiver of Coverage (Spanish)
HSA-Specific (Group)
Optum Bank HSA Employer Notification Form
Optum Bank HSA Employer Contribution Form
HSA-Specific (Member)
Optum Bank Website
Optum Bank HSA Member Application
Optum Bank HSA Consumer Guide
Optum Bank HSA Cardholder Agreement
Optum Bank HSA Custodial and Deposit Agreement
Optum Bank HSA Privacy Notice

New York Small Group (1-50): Healthy New York

Healthy New York Small Employer Group Application
Healthy New York Group Enrollment Agreement
Healthy New York Member Enrollment Form
Healthy New York Re-certification for Small Employers
Dental Enrollment Form
New York Health Benefits Waiver of Coverage

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