Broker Forms

The following forms are being provided to assist you with the management of your Premier Access account. All you need to access your currently enrolled employees’ data is to register on the home page of this website.

Broker Portal Manual

Broker Portal Manual

Broker Appointment Forms

Brokerage Agreement
W-9
HIPAA Business Associate Agreement
Vision Appointment Paperwork
Emdeon ePayment Enrollment and Authorization Form

Employer Forms:

CA -Employer Enrollment Application
AZ -Employer Enrollment Application
NV -Employer Enrollment Application
UT -Employer Enrollment Application
Employer Application Checklist
ACH Bank Draft Form
Plus Plan Disclosure Form

Employee Forms:

Individual Waiver Statement
COBRA Election Enrollment Form
Dental Claim Form
Dentist Nomination Form
Grievance Form — PPO
Grievance Form — DHMO
HIPAA Authorization (English)
HIPAA Authorization (Spanish)

CA:

Employee Application Low High_w_vision-CA
Employee Application Low High-CA
Employee Application PPO_DHMO_w_vision-CA
Employee Application PPO DHMO CA
Employee Application PPO_w_vision CA
Employee Application PPO CA

AZ:

Employee Application Change Form Low-High with Vision-AZ
Employee Application Change Form Low-High-AZ
Employee Application Change Form PPO-DHMO with Vision-AZ
Employee Application Change PPO-DHMO
Employee Application Change Form PPO with Vision-AZ
Employee Application Change Form PPO-AZ

NV:

Employee Application Low High_w_vision-NV
Employee Application Low High-NV
Employee Application PPO_DHMO_w_vision-NV
Employee Application PPO DHMO NV
Employee Application PPO_w_vision NV
Employee Application PPO NV

UT:

Employee Application LowHigh_w_vision UT
Employee Application LowHigh-UT
Employee Application PPO DHMO_w_vision UT
Employee Application PPO DHMO UT
Employee Application PPO_w_vision UT
Employee Application PPO-UT

Note: In order to view these forms, Adobe Acrobat Reader must be installed on your computer. To download Acrobat Reader, click on the adjacent “Get Acrobat Reader” button.

Broker Forms

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