Forms and Documents for Producers

All forms are in Adobe Acrobat format.

Directories:

• Contact Phone List

General:

• Broker Commissions Authorization/Agreement for Direct Deposit
• Commercial Table of Commissions
• Presbyterian Senior Care Table of Commission Rates
• How to Quote and Enroll a  Group with Presbyterian

Guidelines: 

• Field Underwriting Guidelines (Group)
• Individual Underwriting Guidelines - Presbyterian's Individual Plan Field Underwriting Guidelines are currently undergoing revisions. Questions? Please contact your Sales Representative at (505) 923-8200, option 4.

Forms:

• HIPAA - Release of General Health Records Form
• My Care Unique Service Reimbursement Form
• PresMetro Unique Service Reimbursement Form
• Member Termination/Change Form (for groups only)
• Medicare Sales Appointment Confirmation Form

Questions and Answers:

• Commonly asked questions about non-par providers (R&C, DDs etc)
• 4-Tier Prescription Drug commonly asked questions

Presbyterian Group Benefit Information:
Benefit Brief

• Value Care Plans (Group size 2-50 HMO)
• Smart Care Plans (Group size 2-50 HMO)
• PresElect Plans (Group size 2-50 PPO)
• Advantage Care Plans (Group size 2-50 HDHP, qualified HSA plans)
• Choice Care Plans (Group size 4-50 POS) 
• Custom Care Plans (Group size 51+ HMO)
• Smart Care Plans (Group size 51+ HMO)
• Preferred Care Plans (Group size 51+ PPO)
• Advantage Care Plans (Group size 51+ HDHP, qualified HSA plans)
• Flex Care Plans (Group size 51+ POS)

Benefit Summaries by Plan Design - Small Group size 2-50
Benefit Summaries by Plan Design - Large Group size 51+

Riders

• Prescription Riders HMO (Group size 51+)
• Prescription Riders PPO (Group size 51+)
• Benefit Summaries by Prescription Rider Design
• Benefit Summaries by Substance Abuse Rider Design (Group size 51+)  
• VSP Vision Riders (Group size 2+)

Forms for Quoting a Group with Presbyterian

• Rate Request Form
• Census Form
• UMAF Medical Assessment Form/English
• UMAF Medical Assessment Form/Spanish 

Forms for Enrolling a Group with Presbyterian

• Enrollment Checklist 
• Employer Group Information Sheet 
• Employee Action Form PIC/PHP (enrollment /change /waiver) 
• Spanish Employee Action Form PIC/PHP (enrollment /change /waiver) 
• PHP Individual Assessment Form 
• PIC Individual Assessment Form
• Exhibit B, Bank Draft Authorization (Required for Groups 2-9) 
• PEO/Leased Employee Verification Form 
• Transition of Care Form

Individual Plans:

• More information about Presbyterian's Individual Plans 
• Apply Online (temporarily unavailable)
• Individual Enrollment Application

Rates

Active Plan Rate Sheets - (availalble for sale)

• Select Rate
• Classic Rate
• Savvy100 Rate 
• Classic for Kids
• ShortTerm

 Non-Active Plan Rate Sheets  - (not available for sale)

• PresMetro Plus with Dental Rate 
• PresSolo Rate
• Advantage Care Rate 
• Individual Care Rate

Benefits

• Select Plan Benefit Brief
• Classic Plan Benefit Brief
• Savvy100 Plan Benefit Brief
• Classic for Kids Plan Benefit Brief
• ShortTerm Plan Benefit Brief
   
• Delta Dental (Select, Classic, Savvy100 Plans)
• VSP (Select Plans)
   
• PresMetro Plan Benefit Brief (no longer available for new sale)
• PresSolo Plan Benefit Brief (no longer available for new sale)
• Advantage Care Plan Benefit Brief (no longer available for new sale)
   

Benefit Summaries by Plan Design

Individual Plan Member Forms

• Individual Member Add Dependent Form
• Individual Member Termination Form
• PresMetro Unique Services Reimbursement Form
• PresSolo Unique Services Reimbursement Form
• Select Plan Unique Services Reimbursement Form
• Presbyterian HSA Authorization Savvy100 Form

Health Savings Account Information

• Presbyterian HSA Authorization Savvy100 Form

• Health Equity HSA Fact Sheet