Types of forms
- Employee application
- Employee application — Spanish version
- Enrollment application with medical questionnaire
- Enrollment application with medical questionnaire — Spanish version
- Newborn enrollment request
- Active employee application for out-of-area classification
Active employees of Arkansas-based employer groups that live outside of Arkansas for more than 90 days may have access services covered by Health Advantage on the employee’s group health plan, if approved.
- Dependent application for out of area classification
- Prescription claim form
- Prescription claim form - Spanish
- Vision claim form
If you choose to see an out-of-network provider, submit your itemized receipt(s) along with the out-of-network reimbursement form. You will be reimbursed the allotted amount based on your benefits.
- Change request form
This form is used to make changes to a currently enrolled employee's address, name and telephone number or to cancel coverage for an employee and/or dependent(s).
- Explanation of payment form
- Proof of incapacity of a dependent - Physician's form
- Proof of incapacity of a dependent - Policyholder's form
- Reinstatement form
- State of AR continuation of coverage election
- Address change form
- Coordination of benefits questionnaire
- Certificate of coverage (sample)
- Primary care physician selection letter
- Request for member social security number
- Request for continuity of care