Small Group Forms: For Groups with 1-50 Employees
PW_A072237
Colorado Uniform Employee Application for Small Group Health Benefit Plans
Colorado House Bill 05-1312 required that a Colorado Uniform Employee Application for Small Group Health Benefit Plans be created and used by all Colorado health care benefits companies. Effective January 1, 2007, all Colorado employer groups with 1-50 employees must use this state-mandated application when applying for new small group coverage or when requesting changes to their existing coverage. Click here to download this form in Spanish. The Colorado Uniform Employee Application doesn’t include our plan options, so you also must submit the applicable completed Anthem supplemental form. Those forms are listed below.
Note: Please provide all the information requested on the Colorado Uniform Employee Application and the appropriate supplemental form. We’ll return any incomplete or incorrect applications and forms to you, which could delay your enrollment or change request.
Employee Enrollment Supplemental Forms and Employee Enrollment and Change Form for Specialty Products
In addition to submitting the completed Colorado Uniform Employee Application, small group employers also must submit the applicable completed Anthem supplemental form when applying for new small group coverage or when requesting changes to their existing coverage.
Adding Members to the Group’s Health Care Coverage
When adding an employee or covered dependent, including a newborn, to the group’s health care coverage, a completed Colorado Uniform Employee Application for Small Group Health Benefit Plans is required. We also suggest that you submit a completed EmployeeElect or BeneFits supplemental form.
Adding Members to Specialty, State Continuation or COBRA Coverage
When adding an employee or covered dependent to the group’s life, dental or vision coverage, please don’t use the Colorado Uniform Employee Application for Small Group Health Benefit Plans. Instead, only use the application for our specialty products to submit these changes. For COBRA or State Continuation coverage enrollees, use the applicable COBRA or State Continuation enrollment form.
Address Changes
Submit member address changes on the Colorado Uniform Employee Application for Small Group Health Benefit Plans or on the Small Group Information Change Form that’s included with the group’s monthly billing statements. Or, send an e-mail with the address change information to sg@anthem.com. Our EmployeeElect and BeneFits supplemental forms don’t include space for providing address changes only. Submit group address changes on the Small Group Information Change Form or by sending the information in an e-mail to sg@anthem.com. Other Change Requests
When a member is changing coverage from one Anthem Blue Cross and Blue Shield health care plan to another, submit the change on the applicable EmployeeElect or BeneFits supplemental form. For coverage terminations, use the applicable EmployeeElect or BeneFits supplemental form or the Small Group Information Change Form. Or, send the termination information in an e-mail to sg@anthem.com.
General Forms
Individual Authorization Form - This form authorizes Anthem to release a member’s medical information to the person listed on the form.
Psychotherapy Notes Authorization Form - This form authorizes Anthem to release a member’s psychotherapy notes to the person listed on the form.
Health Benefit Plan Description Forms
These Health Benefit Plan Description Forms are the most current versions available. For prior benefit information, please contact your local account manager or sales representative.
EmployeeElect
BeneFits
Boulder Chamber Health Plans
Basic and Standard Plans
Dental Plan Benefit Summaries
These plans are available to groups with 2-50 employees.
Vision Plan Benefit Summaries
These plans are available to groups with 2-50 employees.
Other Health Benefit Plan Description Forms
Note: The products listed below are no longer available for new business; information is provided for renewing business only. To select one of these plans, employees should write the health plan name and prescription drug benefit in the “Other” field in section 1a of the Employee Enrollment Application/Change Form:
BluePreferred PPO Health Plans
PPO HSA Compatible
Enrollment Applications and Change Forms
Affidavit of Common-law Marriage - For adding a common-law spouse and his/her dependents to a policy.
COBRA/State Continuation of Coverage - For requesting continuation of health coverage when a member/dependent coverage is terminated.
Continuity of Care Form - To avoid disruption for a member currently under a provider’s care; approved on a case by case basis up to 90 days in advance.
Anthem Life Insurance Forms - Use the Anthem Life website to access/download Anthem Life forms (other than EmployeeElect application and enrollment forms).
EmployeeElect PPO Plans (for renewing business only):
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