Forms and group administrator manual

The forms listed on the menu below are for use by employers. These forms are in portable document format (PDF). You may print and copy as needed.

Note:

• Groups that submit eligibility electronically or on paper may use these forms.
• Groups that submit electronic enrollment must submit changes to membership information electronically.
• The employee enrollment applications are for use by groups that submit paper enrollment forms only.

Manuals

• Group administrator manual [pdf]

Forms

• Active employee application for out-of-area classification [pdf]
  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.
• Address change form [pdf]
• Blueprint for Employers Registration Form [pdf]
• Blueprint for Employers chief administrator change form [pdf]
• Change request form [pdf]
• Coordination of benefits questionnaire [pdf] 
• Dependent application for out of area classification [pdf]
• Employee application [pdf]
• Employee application — Spanish version [pdf]
• Enrollment application with medical questionnaire [pdf]
• Enrollment application medical questionnaire — Spanish version [pdf]
• Explanation of payment form  [pdf]
• Certificate of coverage (sample) [pdf]
• Newborn enrollment request [pdf]
• Physician incapacity letter [pdf]
• Prescription claim form [pdf]
• Primary care physician selection letter [pdf]
• Proof of incapacity questionnaire [pdf]
• Reinstatement Form [pdf]
• Request for member social security number [pdf]
• State of AR continuation of coverage election [pdf]
• Subscribers incapacity of a dependent [pdf]

Arkansas State Employees / Public School Personnel Group Administrators

• Arkansas employee benefits division forms
  Find the form you need on the Employee Benefits Division website.