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Health Advantage Group Administrator Guidelines

Manuals
  • Group Administrator Manual (PDF)

Forms

    Health Advantage Group Administrators

    • Active Employee Application for Out-of-Area Classification (PDF)

    • Address Change Form (PDF)

    • Billing Adjustment Form (PDF)

    • Blueprint for Employers Change Form (PDF)

    • Blueprint for Employers Registration Form (PDF)

    • Change Request Form (PDF)

    • Coordination of Benefits Questionnaire (PDF)

    • Dependent Application for Out-of-Area Classification (PDF)

    • Dependent Student Verification Letter (PDF)

    • Health Benefits Certificate of Coverage (Sample) (PDF)

    • Large Group Employee Application (PDF)

    • Medical Questionnaire for Late Enrollees (PDF)

    • Newborn Enrollment Request (PDF)

    • Physician Incapacity Letter (PDF)

    • Prescription Claim Form (PDF)

    • Primary-Care Physician Selection Letter (PDF)

    • Proof of Incapacity Questionnaire (PDF)

    • Request for Member Social Security Number (PDF)

    • Small Group Employee Application (PDF)

    • State of Arkansas Continuation of Coverage Election Form (PDF)

    • Student Verification Form (PDF)

    • Subscriber's Incapacity Form (PDF)

    Arkansas State Employees/Public School Personnel Group Administrators

    • Arkansas Employee Benefits Division Forms Find the form you need on the Employee Benefits Division Web site.

    • Other Insurance/Coordination of Benefits (COB) (PDF) Do you have other insurance? Fill out this form, and let us know.



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Shield Association and is licensed to offer health plans in all 75 counties in Arkansas.
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