Health Advantage Group Administrator Guidelines

• Group Administrator Guidelines (Electronic Eligibility/Enrollment) (286 KB PDF)
  
  
• Group Administrator Guidelines (Paper Enrollment) (275 KB PDF)
  
  

Forms

Health Advantage Group Administrators

• Active Employee Application for Out-of-Area Classification (38 KB PDF)
  
  
• Address Change Form (78 KB PDF)
  
  
• Billing Adjustment Form (8 KB PDF)
  
  
• BluePrint for Employers Change Form (34 KB PDF)
  
  
• BluePrint for Employers Registration Form (50 KB PDF)
  
  
• Change Request Form (64 KB PDF)
  
  
• Coordination of Benefits Questionnaire (40 KB PDF)
  
  
• Dependent Application for Out-of-Area Classification (81 KB PDF)
  
  
• Dependent Student Verification Letter (26 KB PDF)
  
  
• Health Benefits Certificate of Coverage (Sample) (34 KB PDF)
  
  
• Large Group Employee Application (138 KB PDF)
  
  
• Medical Questionnaire for Late Enrollees (144 KB PDF)
  
  
• Newborn Enrollment Request (36 KB PDF)
  
  
• Physician incapacity letter (54 KB PDF)
  
  
• Prescription Claim Form (882 KB PDF)
  
  
• Primary-Care Physician Selection Letter (35 KB PDF)
  
  
• Proof of Incapacity Questionnaire (69 KB PDF)
  
  
• Request for Member Social Security Number (42 KB PDF)
  
  
• Small Group Employee Application (156 KB PDF)
  
  
• Student Verification Form (44 KB PDF)
  
  
• Subscriber's Incapacity Form (85 KB 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) (40 KB PDF) Do you have other insurance? Fill out this form, and let us know.
  
  

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