The following forms are being provided to assist you with the management of your Premier Access portfolio.
And don’t forget…specific group information is available through the interactive portion of this website. All you need to access your currently enrolled employees’ data is to register on the home page of this website.
Broker Appointment Forms
- Brokerage Agreement
- W-9
- HIPAA Business Associate Agreement
- Vision Appointment Paperwork
- Emdeon ePayment Enrollment and Authorization Form
Employer Forms
- Employer Enrollment Application
- Employer Application Checklist
- Vision Employer Application
- ACH Bank Draft Form
- Plus Plan Disclosure Form
Employee Forms
- Employee Enrollment/Change Form (English)
- Employee Enrollment/Change Form (Spanish)
- Employee Enrollment/Change Form with Vision (English)
- Employee Enrollment/Change Form with Vision (Spanish)
- Individual Waiver Statement
- COBRA Election Enrollment Form
- Dentist Nomination Form
- Dental Claim Form
- Grievance Form — PPO
- Grievance Form — DHMO
- HIPAA Authorization (English)
- HIPAA Authorization (Spanish)
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.
