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Applications & Forms

The following is a list of our online forms and applications. Looking for group sales literature?

Individual Medical

QHP

North Region
For residents of the following counties: Benewah, Bonner, Boundary, Clearwater, Idaho, Kootenai, Latah, Lewis, Nez Perce and Shoshone counties


Idaho Individual Application & Cover Sheet - North Region online-fillable form 3-1179
Qualified Health Plan Products Change Form - North Region online-fillable form 3-1182

Southwest Region
For residents of the following counties: Ada, Adams, Blaine, Boise, Camas, Canyon, Cassia, (for CarePoint St. Luke’s Health Partners plan applicants), Elmore, Gem, Gooding, Jerome, Lincoln, Minidoka, Owyhee, Payette, Twin Falls, Valley and Washington counties


Idaho Individual Application & Cover Sheet - SW Region online-fillable form 3-1180
Qualified Health Plan Products Change Form - SW Region online-fillable form 3-1183

East/Southeast Idaho Region
For residents of the following counties: Bannock, Bear Lake, Bingham, Bonneville, Butte, Caribou, Cassia (for Hometown East plan applicants), Clark, Custer, Franklin, Fremont, Jefferson, Lemhi, Madison, Minidoka, Oneida, Power and Teton counties


Idaho Individual Application & Cover Sheet - East/SE Region online-fillable form 3-1178
Qualified Health Plan Products Change Form - East/SE Region online-fillable form 3-1181

Grandfathered and Grandmothered

Idaho Individual Application IND-APP-11-2010  
Transfer Application 3-362

Medicare Supplement

Prime 65sm Application 3-334

Short Term

Short Term PPO Application 3-614A
Spanish Short Term PPO Application 3-614A SP

Dental

Healthy Smiles Application 3-052a
Healthy Smiles Application - bilingual 3-052a-s
Individual QHP Dental Choice & Dental Choice Application 3-189A

General Maintenance Forms

2016 Qualified Health Plan Change Form online-fillable form 3-929
Authorization Agreement for Automatic Withdrawal 3-449
Authorization to Delete Dependent  
Certification of Non-Use of Tobacco 3-319
Enrollment Validation Form (Validation of Idaho Residency & Qualifying Life Event)  

Group Medical

We've combined our coversheet and application into one PDF that can be used for all group sizes and both pre-ACA and post-ACA plans. We hope this makes the application process easier for you and your groups.

Idaho Universal Group Application width Cover Sheet online-fillable form

  • For all groups excluding the below
3-1231

Idaho Universal Group Application with Cover Sheet and Health Statement online-fillable form

  • For all new medium groups
  • For all new large groups not using claims experience
  • For existing small grandfathered/ grandmothered groups if enrollment addition exceeds 20% threshold
3-1230

Idaho Universal Group Application Cover Sheet online-fillable form

3-1157C
Group Standalone Dental Enrollment Application online-fillable form 3-395
Group Voluntary Vision Enrollment Application 3-412
Statewide Schools Retiree Application online-fillable form 4-150
Statewide Schools ASC Health/Dental/Vision Enrollment Application online-fillable form 3-307SWS

Other Group Forms

Small Group Large Group Form Description Form #
X   Employee Census Data 3-468
X   Employer Application & Questionnaire for New Small Group Coverage 3-549
X   Group Quoting System Excel Roster (.zip file)  
X   Universal Idaho Small Employer Application - Spanish online-fillable form 3-017S
X X Plan Change Form Multi Option Groups online-fillable form 3-128
X X Employee's Waiver of Health Care Coverage online-fillable form 3-467
X X Group Contact Change Form 3-1146
X X Group Letter of Record online-fillable form 3-302
X X Third Party COBRA Notification online-fillable form 3-1125
X X Probationary Period Waiver Request 3-183
  X Employer Application & Group Questionnaire for New Groups 51 or more Employees online-fillable form 3-550
  X Employer Application & Group Questionnaire for New ASC Groups online-fillable form 3-437
  X Private Exchange Application & Questionnaire for Mid & Large Groups online-fillable form 3-1208
  X Spanish - Idaho Large Employer Group Application & Cover Sheet online-fillable form 3-186S

Additional Forms/Resources

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