Forms and documents Oregon

Forms and documents

Plan confirmation forms for groups 1-50

• 1-50 Group Plan Confirmation Form – confirm group coverage with us

Employer enrollment forms

• Group Application 1-50 (2024) – use to enroll a group of 1-50
• Group Size Determination Form – use to see if a group qualifies as a small group
• Authorization Agreement Form (EFT) – Group – provides authorization for electronic funds transfer

Benefit Summaries

• Access Benefit Summaries (SOBs) for groups 1-50

Individual resources

• Oregon Individual and family dental plans brochure

Enrollment application & change of information forms

• Dental
• Dental (Español)
• Dual Dental
• Dual Dental (Español)

Domestic partnership documentation

• Domestic partnership documentation for qualified plans – use this form for domestic partnership documentation

Quote request

• Census Form (Excel) – request a quote
• Proposal Request Form (Excel) – request a proposal

Claims

• Claims form – Log in to Member dashboard to access claim form
• Sample EOB document – see what an explanation of benefits (EOB) looks like

Coordination of Benefits

• Coordination of Benefits form  – use this form to provide information about other health or dental plans members may have