Forms & Brochures – Small Business Group Plans

Full Network HMO

• SBC – Full Network HMO Platinum $0 (PDF)
• SBC – Full Network HMO Platinum $0 + Infertility (PDF)
• SBC – Full Network HMO Platinum $10 (PDF)
• SBC – Full Network HMO Platinum $10 + Infertility (PDF)
• SBC – Full Network HMO Platinum $20 (PDF)
• SBC – Full Network HMO Platinum $20 + Infertility (PDF)
• SBC – Full Network HMO Platinum $30 (PDF)
• SBC – Full Network HMO Platinum $30 + Infertility (PDF)
• SBC – Full Network HMO Platinum $35 (PDF)
• SBC – Full Network HMO Platinum $35 + Infertility (PDF)
• SBC – Full Network HMO Gold $30 (PDF)
• SBC – Full Network HMO Gold $30 + Infertility (PDF)
• SBC – Full Network HMO Gold $35 (PDF)
• SBC – Full Network HMO Gold $35 + Infertility (PDF)
• SBC – Full Network HMO Gold $40 (PDF)
• SBC – Full Network HMO Gold $40 + Infertility (PDF)
• SBC – Full Network HMO Gold $50 (PDF)
• SBC – Full Network HMO Gold $50 + Infertility (PDF)
• SBC – Full Network HMO Gold $55 (PDF)
• SBC – Full Network HMO Gold $55 + Infertility (PDF)
• SBC – Full Network HMO Silver $55 (PDF)
• SBC – Full Network HMO Silver $55 + Infertility (PDF)

Salud HMO y Más

• SBC – Salud HMO y Más Platinum $0 (PDF)
• SBC – Salud HMO y Más Platinum $0 + Infertility (PDF)
• SBC – Salud HMO y Más Platinum $10 (PDF)
• SBC – Salud HMO y Más Platinum $10 + Infertility (PDF)
• SBC – Salud HMO y Más Platinum $20 (PDF)
• SBC – Salud HMO y Más Platinum $20 + Infertility (PDF)
• SBC – Salud HMO y Más Platinum $30 (PDF)
• SBC – Salud HMO y Más Platinum $30 + Infertility (PDF)
• SBC – Salud HMO y Más Platinum $35 (PDF)
• SBC – Salud HMO y Más Platinum $35 + Infertility (PDF)
• SBC – Salud HMO y Más Gold $30 (PDF)
• SBC – Salud HMO y Más Gold $30 + Infertility (PDF)
• SBC – Salud HMO y Más Gold $35 (PDF)
• SBC – Salud HMO y Más Gold $35 + Infertility (PDF)
• SBC – Salud HMO y Más Gold $40 (PDF)
• SBC – Salud HMO y Más Gold $40 + Infertility (PDF)
• SBC – Salud HMO y Más Gold $50 (PDF)
• SBC – Salud HMO y Más Gold $50 + Infertility (PDF)
• SBC – Salud HMO y Más Gold $55 (PDF)
• SBC – Salud HMO y Más Gold $55 + Infertility (PDF)
• SBC – Salud HMO y Más Silver $55 (PDF)
• SBC – Salud HMO y Más Silver $55 + Infertility (PDF)

SmartCare HMO

• SBC – SmartCare HMO Platinum $0 (PDF)
• SBC – SmartCare HMO Platinum $0 + Infertility (PDF)
• SBC – SmartCare HMO Platinum $10 (PDF)
• SBC – SmartCare HMO Platinum $10 + Infertility (PDF)
• SBC – SmartCare HMO Platinum $20 (PDF)
• SBC – SmartCare HMO Platinum $20 + Infertility (PDF)
• SBC – SmartCare HMO Platinum $30 (PDF)
• SBC – SmartCare HMO Platinum $30 + Infertility (PDF)
• SBC – SmartCare HMO Platinum $35 (PDF)
• SBC – SmartCare HMO Platinum $35 + Infertility (PDF)
• SBC – SmartCare HMO Gold $30 (PDF)
• SBC – SmartCare HMO Gold $30 + Infertility (PDF)
• SBC – SmartCare HMO Gold $35 (PDF)
• SBC – SmartCare HMO Gold $35 + Infertility (PDF)
• SBC – SmartCare HMO Gold $40 (PDF)
• SBC – SmartCare HMO Gold $40 + Infertility (PDF)
• SBC – SmartCare HMO Gold $50 (PDF)
• SBC – SmartCare HMO Gold $50 + Infertility (PDF)
• SBC – SmartCare HMO Gold $55 (PDF)
• SBC – SmartCare HMO Gold $55 + Infertility (PDF)
• SBC – SmartCare HMO Silver $55 (PDF)
• SBC – SmartCare HMO Silver $55 + Infertility (PDF)

WholeCare HMO

• SBC – WholeCare HMO Platinum $0 (PDF)
• SBC – WholeCare HMO Platinum $0 + Infertility (PDF)
• SBC – WholeCare HMO Platinum $10 (PDF)
• SBC – WholeCare HMO Platinum $10 + Infertility (PDF)
• SBC – WholeCare HMO Platinum $20 (PDF)
• SBC – WholeCare HMO Platinum $20 + Infertility (PDF)
• SBC – WholeCare HMO Platinum $30 (PDF)
• SBC – WholeCare HMO Platinum $30 + Infertility (PDF)
• SBC – WholeCare HMO Platinum $35 (PDF)
• SBC – WholeCare HMO Platinum $35 + Infertility (PDF)
• SBC – WholeCare HMO Gold $30 (PDF)
• SBC – WholeCare HMO Gold $30 + Infertility (PDF)
• SBC – WholeCare HMO Gold $35 (PDF)
• SBC – WholeCare HMO Gold $35 + Infertility (PDF)
• SBC – WholeCare HMO Gold $40 (PDF)
• SBC – WholeCare HMO Gold $40 + Infertility (PDF)
• SBC – WholeCare HMO Gold $50 (PDF)
• SBC – WholeCare HMO Gold $50 + Infertility (PDF)
• SBC – WholeCare HMO Gold $55 (PDF)
• SBC – WholeCare HMO Gold $55 + Infertility (PDF)
• SBC – WholeCare HMO Silver $55 (PDF)
• SBC – WholeCare HMO Silver $55 + Infertility (PDF)

PPO

• SBC – Platinum PPO 0/5 (PDF)
• SBC – Platinum PPO 0/5 INF (PDF)
• SBC – Platinum PPO 0/15 (PDF)
• SBC – Platinum PPO 0/15 INF (PDF)
• SBC – Platinum PPO 250/15 (PDF)
• SBC – Platinum PPO 250/15 INF (PDF)
• SBC – Gold PPO 350/25 (PDF)
• SBC – Gold PPO 350/25 INF (PDF)
• SBC – Gold PPO 1000/35 (PDF)
• SBC – Gold PPO 1000/35 INF (PDF)
• SBC – Gold PPO 750/15 (PDF)
• SBC – Gold PPO 750/15 INF (PDF)
• SBC – Gold PPO 0/35 (PDF)
• SBC – Gold PPO 0/35 INF (PDF)
• SBC – Gold PPO 500/20 (PDF)
• SBC – Gold PPO 500/20 INF (PDF)
• SBC – Gold PPO 1500/20 INF (PDF)
• SBC – Gold PPO 1500/20 INF (PDF)
• SBC – Gold HDHP PPO 1650/20% (PDF)
• SBC – Gold HDHP PPO 1650/20% INF (PDF)
• SBC – Silver PPO 2500/50 (PDF)
• SBC – Silver PPO 2500/50 INF (PDF)
• SBC – Silver PPO 2500/55 (PDF)
• SBC – Silver PPO 2500/55 INF (PDF)
• SBC – Silver PPO 2250/60 (PDF)
• SBC – Silver PPO 2250/60 INF (PDF)
• SBC – Silver PPO 1700/50 (PDF)
• SBC – Silver PPO 1700/50 INF (PDF)
• SBC – Silver HDHP PPO 1650/50% (PDF)
• SBC – Silver HDHP PPO 1650/50% INF (PDF)
• SBC – Bronze PPO 5800/60 (PDF)
• SBC – Bronze PPO 5800/60 INF (PDF)
• SBC – Bronze HDHP PPO 6650/0% (PDF)
• SBC – Bronze HDHP PPO 6650/0% INF (PDF)

CommunityCare HMO

• SBC – CommunityCare HMO Silver $2250/$50 (PDF)
• SBC – CommunityCare HMO Silver $2250/$50 + Infertility (PDF)
• SBC – CommunityCare HMO Bronze $6300/60 (PDF)
• SBC – CommunityCare HMO Bronze $6300/60 + Infertility (PDF)

Full Network HMO

• SBC – Full Network HMO Platinum $0 (PDF)
• SBC – Full Network HMO Platinum $0 + Infertility (PDF)
• SBC – Full Network HMO Platinum $10 (PDF)
• SBC – Full Network HMO Platinum $10 + Infertility (PDF)
• SBC – Full Network HMO Platinum $20 (PDF)
• SBC – Full Network HMO Platinum $20 + Infertility (PDF)
• SBC – Full Network HMO Platinum $30 (PDF)
• SBC – Full Network HMO Platinum $30 + Infertility (PDF)
• SBC – Full Network HMO Platinum $35 (PDF)
• SBC – Full Network HMO Platinum $35 + Infertility (PDF)
• SBC – Full Network HMO Gold $30 (PDF)
• SBC – Full Network HMO Gold $30 + Infertility (PDF)
• SBC – Full Network HMO Gold $35 (PDF)
• SBC – Full Network HMO Gold $35 + Infertility (PDF)
• SBC – Full Network HMO Gold $40 (PDF)
• SBC – Full Network HMO Gold $40 + Infertility (PDF)
• SBC – Full Network HMO Gold $50 (PDF)
• SBC – Full Network HMO Gold $50 + Infertility (PDF)
• SBC – Full Network HMO Gold $55 (PDF)
• SBC – Full Network HMO Gold $55 + Infertility (PDF)
• SBC – Full Network HMO Silver $55 (January-September) (PDF)
• SBC – Full Network HMO Silver $55 (October-December) (PDF)
• SBC – Full Network HMO Silver $55 + Infertility (January-September) (PDF)
• SBC – Full Network HMO Silver $55 + Infertility (October-December) (PDF)

Salud HMO y Más

• SBC – Salud HMO y Más Platinum $0 (PDF)
• SBC – Salud HMO y Más Platinum $0 + Infertility (PDF)
• SBC – Salud HMO y Más Platinum $10 (PDF)
• SBC – Salud HMO y Más Platinum $10 + Infertility (PDF)
• SBC – Salud HMO y Más Platinum $20 (PDF)
• SBC – Salud HMO y Más Platinum $20 + Infertility (PDF)
• SBC – Salud HMO y Más Platinum $30 (PDF)
• SBC – Salud HMO y Más Platinum $30 + Infertility (PDF)
• SBC – Salud HMO y Más Platinum $35 (PDF)
• SBC – Salud HMO y Más Platinum $35 + Infertility (PDF)
• SBC – Salud HMO y Más Gold $30 (PDF)
• SBC – Salud HMO y Más Gold $30 + Infertility (PDF)
• SBC – Salud HMO y Más Gold $35 (PDF)
• SBC – Salud HMO y Más Gold $35 + Infertility (PDF)
• SBC – Salud HMO y Más Gold $40 (PDF)
• SBC – Salud HMO y Más Gold $40 + Infertility (PDF)
• SBC – Salud HMO y Más Gold $50 (PDF)
• SBC – Salud HMO y Más Gold $50 + Infertility (PDF)
• SBC – Salud HMO y Más Gold $55 (PDF)
• SBC – Salud HMO y Más Gold $55 + Infertility (PDF)
• SBC – Salud HMO y Más Silver $55 (January-September) (PDF)
• SBC – Salud HMO y Más Silver $55 (October-December) (PDF)
• SBC – Salud HMO y Más Silver $55 + Infertility (January-September) (PDF)
• SBC – Salud HMO y Más Silver $55 + Infertility (October-December) (PDF)

SmartCare HMO

• SBC – SmartCare HMO Platinum $0 (PDF)
• SBC – SmartCare HMO Platinum $0 + Infertility (PDF)
• SBC – SmartCare HMO Platinum $10 (PDF)
• SBC – SmartCare HMO Platinum $10 + Infertility (PDF)
• SBC – SmartCare HMO Platinum $20 (PDF)
• SBC – SmartCare HMO Platinum $20 + Infertility (PDF)
• SBC – SmartCare HMO Platinum $30 (PDF)
• SBC – SmartCare HMO Platinum $30 + Infertility (PDF)
• SBC – SmartCare HMO Platinum $35 (PDF)
• SBC – SmartCare HMO Platinum $35 + Infertility (PDF)
• SBC – SmartCare HMO Gold $30 (PDF)
• SBC – SmartCare HMO Gold $30 + Infertility (PDF)
• SBC – SmartCare HMO Gold $35 (PDF)
• SBC – SmartCare HMO Gold $35 + Infertility (PDF)
• SBC – SmartCare HMO Gold $40 (PDF)
• SBC – SmartCare HMO Gold $40 + Infertility (PDF)
• SBC – SmartCare HMO Gold $50 (PDF)
• SBC – SmartCare HMO Gold $50 + Infertility (PDF)
• SBC – SmartCare HMO Gold $55 (PDF)
• SBC – SmartCare HMO Gold $55 + Infertility (PDF)
• SBC – SmartCare HMO Silver $55 (January-September) (PDF)
• SBC – SmartCare HMO Silver $55 (October-December) (PDF)
• SBC – SmartCare HMO Silver $55 + Infertility (January-September) (PDF)
• SBC – SmartCare HMO Silver $55 + Infertility (October-December) (PDF)

WholeCare HMO

• SBC – WholeCare HMO Platinum $0 (PDF)
• SBC – WholeCare HMO Platinum $0 + Infertility (PDF)
• SBC – WholeCare HMO Platinum $10 (PDF)
• SBC – WholeCare HMO Platinum $10 + Infertility (PDF)
• SBC – WholeCare HMO Platinum $20 (PDF)
• SBC – WholeCare HMO Platinum $20 + Infertility (PDF)
• SBC – WholeCare HMO Platinum $30 (PDF)
• SBC – WholeCare HMO Platinum $30 + Infertility (PDF)
• SBC – WholeCare HMO Platinum $35 (PDF)
• SBC – WholeCare HMO Platinum $35 + Infertility (PDF)
• SBC – WholeCare HMO Gold $30 (PDF)
• SBC – WholeCare HMO Gold $30 + Infertility (PDF)
• SBC – WholeCare HMO Gold $35 (PDF)
• SBC – WholeCare HMO Gold $35 + Infertility (PDF)
• SBC – WholeCare HMO Gold $40 (PDF)
• SBC – WholeCare HMO Gold $40 + Infertility (PDF)
• SBC – WholeCare HMO Gold $50 (PDF)
• SBC – WholeCare HMO Gold $50 + Infertility (PDF)
• SBC – WholeCare HMO Gold $55 (PDF)
• SBC – WholeCare HMO Gold $55 + Infertility (PDF)
• SBC – WholeCare HMO Silver $55 (January-September) (PDF)
• SBC – WholeCare HMO Silver $55 (October-December) (PDF)
• SBC – WholeCare HMO Silver $55 + Infertility (January-September) (PDF)
• SBC – WholeCare HMO Silver $55 + Infertility (October-December) (PDF)

PPO

• SBC – Platinum PPO 0/15 (PDF)
• SBC – Platinum PPO 0/15 INF (PDF)
• SBC – Platinum PPO 250/15 (PDF)
• SBC – Platinum PPO 250/15 INF (PDF)
• SBC – Gold PPO 0/35 (PDF)
• SBC – Gold PPO 0/35 INF (PDF)
• SBC – Gold PPO 1000/35 (PDF)
• SBC – Gold PPO 1000/35 INF (PDF)
• SBC – Gold PPO 1600/0 INF (PDF)
• SBC – Gold PPO 1600/0 INF (PDF)
• SBC – Gold PPO 350/25 (PDF)
• SBC – Gold PPO 350/25 INF (PDF)
• SBC – Gold PPO 500/20 (PDF)
• SBC – Gold PPO 500/20 INF (PDF)
• SBC – Gold PPO 750/15 (PDF)
• SBC – Gold PPO 750/15 INF (PDF)
• SBC – Gold HDHP PPO 1600/20% (PDF)
• SBC – Gold HDHP PPO 1600/20% INF (PDF)
• SBC – Silver HDHP PPO 1600/50% (PDF)
• SBC – Silver HDHP PPO 1600/50% INF (PDF)
• SBC – Silver PPO 2250/60 (PDF)
• SBC – Silver PPO 2250/60 INF (PDF)
• SBC – Silver PPO 2500/55 (PDF)
• SBC – Silver PPO 2500/55 INF (PDF)
• SBC – Silver PPO 1700/50 (PDF)
• SBC – Silver PPO 1700/50 INF (PDF)
• SBC – Bronze HDHP PPO 7050/0% (PDF)
• SBC – Bronze HDHP PPO 7050/0% INF (PDF)
• SBC – Bronze PPO 6300/60 (PDF)
• SBC – Bronze PPO 6300/60 INF (PDF)

HMO Disclosure Forms

Full Network HMO

• Disclosure Form – Full Network HMO – English (PDF)
• Disclosure Form – Full Network HMO – En Español (Spanish) (PDF)
• Disclosure Form – Full Network HMO – Chinese (PDF)
• Disclosure Form – Full Network HMO – Korean (PDF)

SmartCare HMO

• Disclosure Form – SmartCare HMO – English (PDF)
• Disclosure Form – SmartCare HMO – En Español (Spanish) (PDF)
• Disclosure Form – SmartCare HMO – Chinese (PDF)
• Disclosure Form – SmartCare HMO – Korean (PDF)

WholeCare HMO

• Disclosure Form – WholeCare HMO – English (PDF)
• Disclosure Form – WholeCare HMO – En Español (Spanish) (PDF)
• Disclosure Form – WholeCare HMO – Chinese (PDF)
• Disclosure Form – WholeCare HMO – Korean (PDF)

Salud HMO y Más

• Disclosure Form – Salud HMO y Más – English (PDF)
• Disclosure Form – Salud HMO y Más – En Español (Spanish) (PDF)
• Disclosure Form – Salud HMO y Más – Chinese (PDF)
• Disclosure Form – Salud HMO y Más – Korean (PDF)

PPO Disclosure Forms

Full Network PPO

• Disclosure Form – Full Network PPO – English (PDF)
• Disclosure Form – Full Network PPO – En Español (Spanish) (PDF)
• Disclosure Form – Full Network PPO – Chinese (PDF)
• Disclosure Form – Full Network PPO – Korean (PDF)

HMO Disclosure Forms

CommunityCare HMO

• DF – CommunityCare HMO – English (PDF)
• DF – CommunityCare HMO – Spanish (PDF)
• DF – CommunityCare HMO – Chinese (PDF)
• DF – CommunityCare HMO – Korean (PDF)
• DF – CommunityCare HMO – Vietnamese (PDF)

Full Network HMO

• DF – Full Network HMO – English (PDF)
• DF – Full Network HMO – Spanish (PDF)
• DF – Full Network HMO – Chinese (PDF)
• DF – Full Network HMO – Korean (PDF)
• DF – Full Network HMO – Vietnamese (PDF)

SmartCare HMO

• DF – SmartCare HMO – English (PDF)
• DF – SmartCare HMO – Spanish (PDF)
• DF – SmartCare HMO – Chinese (PDF)
• DF – SmartCare HMO – Korean (PDF)
• DF – SmartCare HMO – Vietnamese (PDF)
  

WholeCare HMO

• DF – WholeCare HMO – English (PDF)
• DF – WholeCare HMO – Spanish (PDF)
• DF – WholeCare HMO – Chinese (PDF)
• DF – WholeCare HMO – Korean (PDF)
• DF – WholeCare HMO – Vietnamese (PDF)
  

Salud HMO y Más

• DF – Salud HMO y Más – English (PDF)
• DF – Salud HMO y Más – Spanish (PDF)
• DF – Salud HMO y Más – Chinese (PDF)
• DF – Salud HMO y Más – Korean (PDF)
• DF – Salud HMO y Más – Vietnamese (PDF)

PPO Disclosure Forms

Full Network PPO

• DF – Full Network PPO – English (PDF)
• DF – Full Network PPO – Spanish (PDF)
• DF – Full Network PPO – Chinese (PDF)
• DF – Full Network PPO – Korean (PDF)
• DF – Full Network PPO – Vietnamese (PDF)
  

• Portfolio Plan Desktopper – 2025 – English (PDF)
• Portfolio Plan Desktopper – 2024 – English (PDF)
• Portfolio Guide – January 2025 – English (PDF)
• Portfolio Guide – January 2024 – English (PDF)
• Benefit Crosswalk – 2025 – English (PDF)
• Benefit Crosswalk – 2024 – English (PDF)
• Q1 2025 Renewal Guide – English (PDF)
• Q1 2024 Renewal Guide – English (PDF)
• Broker PPO Fast Facts flyer – English (PDF)

Presentation Folders

Note: For example only. Folders can be ordered on CustomPoint

• Generic Folder – English (PDF)
• Open Enrollment Folder – English (PDF)
• Open Enrollment Folder – En Español (Spanish) (PDF)

Open Enrollment Product flyers

To be used as inserts with the OE Folders, may not be used as stand-alone flyers.

• Open Enrollment Product flyer – HMO – English (PDF)
• Open Enrollment Product flyer – HMO – En Español (Spanish) (PDF)
• Open Enrollment Product flyer – PPO – English (PDF)
• Open Enrollment Product flyer – PPO – En Español (Spanish) (PDF)

Ancillary Add-On or Change Form

Ancillary Add-On or Change Form – English (PDF)

Enrollment and Change Applications

Employee Enrollment and Change Form (2025)

• Employee Enrollment and Change Form (2025) – English (PDF)
• Employee Enrollment and Change Form (2025) – En Español (Spanish) (PDF)
• Employee Enrollment and Change Form (2025) – 中文 (Chinese) (PDF)
• Employee Enrollment and Change Form (2025) – 한국어 (Korean) (PDF)

Employee Enrollment and Change Form (2024)

• Employee Enrollment and Change Form (2024) – English (PDF)
• Employee Enrollment and Change Form (2024) – En Español (Spanish) (PDF)
• Employee Enrollment and Change Form (2024) – 中文 (Chinese) (PDF)
• Employee Enrollment and Change Form (2024) – 한국어 (Korean) (PDF)

Employee Enrollment and Change Form (2023)

• Employee Enrollment and Change Form (2023) – English (PDF)
• Employee Enrollment and Change Form (2023) – En Español (Spanish) (PDF)
• Employee Enrollment and Change Form (2023) – 中文 (Chinese) (PDF)
• Employee Enrollment and Change Form (2023) – 한국어 (Korean) (PDF)
• Employee Enrollment and Change Form (2023) – Tiếng Việt (Vietnamese) (PDF)

Renewal Election and Open Enrollment Medical Plan Change Request Form

• Renewal Election and Open Enrollment Medical Plan Change Request Form – 2025 – English (PDF)
• Renewal Election and Open Enrollment Medical Plan Change Request Form – 2024 – English (PDF)

Must be completed & signed by the Employer Group.

Application for Group Service Agreement/Policy

• Application for Group Service Agreement/Policy – 2025 – English (PDF)
• Application for Group Service Agreement/Policy – January 2024 – English (PDF)
• Application for Group Service Agreement/Policy – January 2023 – English (PDF)

Must be completed & signed by the Employer Group and Broker at time of enrollment and submitted along with check for first month's premium and enrollment forms. For renewals, this form must be completed and signed by the Employer Group and submitted to SBG Account Management for processing.

Religious Exemption Employer Form

Religious Exemption Employer Form – English (PDF)

Transition of Care

• Continuity of Care Assistance Request Form – English (PDF)
• Continuity of Care Assistance Request Form – En Español (Spanish) (PDF)
• Prescription Transition form – English (PDF)
• Prescription Transition form – En Español (Spanish) (PDF)

Claims

• Commercial Medical Claim Form – English (PDF)
• Commercial Medical Claim Form – En Español (Spanish) (PDF)
• Commercial Behavioral Health Claim Form – English (PDF)
• Prescription Drug Claim Form – English (PDF)
• Prescription Drug Claim Form – En Español (Spanish) (PDF)
• Dental Claim Form – English (PDF)
• Vision Claim Form – English (PDF)

HIPAA Disclosures

• Group Health Plan HIPAA Disclosure Forms – Disclosure Directive
• Authorization For Disclosure of PHI – English (PDF)
• Authorization For Disclosure of PHI – En Español (Spanish) (PDF)
• Authorization For Disclosure of PHI – 中文 (Chinese) (PDF)
• Authorization For Disclosure of PHI – 한국어 (Korean) (PDF)

Health Net Life Insurance Forms

• Application to Convert Group Life – English (PDF)
• Evidence of Insurability Life Form – English (PDF)
• Life Insurance Claim Form – English (PDF)
• Life Insurance Claim Form – En Español (Spanish) (PDF)
• Member Life Insurance Waiver of Premium Claim Form – English (PDF)

Additional Forms

• Employer Group Size Attestation Form – English (PDF)
• Electronic Check Form – English (PDF)
• Proof of Eligibility Statement For Sole Proprietor, Partner or Corporate Officer – English (PDF)
• Principal Business or Headquarters Address Questionnaire – English (PDF)

New to Health Net? Contact Health Net Account Management, 1-800-447-8812, option 2, for questions on standard benefit rates.

Looking for CalChoice or Covered California Small Business rates? Visit the CalChoice website, or contact Covered California Small Business at 1-877-752-4737.

Standard

2025

• Q1 2025 – Standard Rate Guide – English (PDF)
  Rates effective January 1, 2025 through March 31, 2025

2024

• Q4 2024 – Standard Rate Guide – English (PDF)
  Rates effective October 1, 2024 through December 31, 2024
• Q3 2024 – Standard Rate Guide – English (PDF)
  Rates effective July 1, 2024 through September 30, 2024
• Q2 2024 – Standard Rate Guide – English (PDF)
  Rates effective April 1, 2024 through June 30, 2024
• Q1 2024 – Standard Rate Guide – English (PDF)
  Rates effective January 1, 2024 through March 31, 2024

2023

• Q4 2023 – Standard Rate Guide – English (PDF)
  Rates effective October 1, 2023 through December 31, 2023
• Q3 2023 – Standard Rate Guide – English (PDF)
  Rates effective July 1, 2023 through September 30, 2023
• Q2 2023 – Standard Rate Guide – English (PDF)
  Rates effective April 1, 2023 through June 30, 2023
• Q1 2023 – Standard Rate Guide – English (PDF)
  Rates effective January 1, 2023 through March 31, 2023

Underwriting Promotions

• Underwriting Promotions 2025 – English (PDF)
• Underwriting Promotions 2024 – English (PDF)

Underwriting Guidelines – January 2025

• January 2025 – Enhanced Choice – English (PDF)
• January 2025 – Dental and Vision – English (PDF)
• January 2025 – Health Net Life – English (PDF)

Underwriting Guidelines – January 2024

• January 2024 – Enhanced Choice – English (PDF)
• January 2024 – Dental and Vision – English (PDF)
• January 2024 – Health Net Life – English (PDF)

Underwriting Guidelines – January 2023

• January 2023 – Enhanced Choice – English (PDF)
• January 2023 – Dental and Vision – English (PDF)
• January 2023 – Health Net Life – English (PDF)

Underwriting Guidelines – March 2022

• March 2022 – Enhanced Choice A – English (PDF)
• March 2022 – Enhanced Choice B – English (PDF)
• March 2022 – Dental and Vision – English (PDF)
• March 2022 – Health Net Life – English (PDF)

Sales Support Tools and Broker Materials

• Commercial Sales Guidelines – English (PDF)
• Health Net Financial Strength and Stability – English (PDF)
• Why Health Net? – English (PDF)
• Health Net Value Add Programs – English (PDF)
• Health Net Value Add Programs – En Español (Spanish) (PDF)
• How To Read Your Commission Statement – English (PDF)
• Manage your Business in the Broker Portal – English (PDF)
• Prior-Carrier Deductible Credit Flyer – English (PDF)

CommunityCare

• CommunityCare HMO Sell Sheet – 2023 – English (PDF)

Care Access

• Same Day Care – English (PDF)
• Same Day Care – En Español (Spanish) (PDF)
• Health Net Doula Program – English (PDF)
• Health Net Doula Program – En Español (Spanish) (PDF)
• Teladoc Commercial Mental Health Flyer – English (PDF)
• Teladoc Health Member FAQs – English (PDF)
• Teladoc Health Member FAQs – En Español (Spanish) (PDF)
• Teladoc Health Member Flyer – English (PDF)
• Teladoc Health Member Flyer – En Español (Spanish) (PDF)
• Understanding the Continuity of Care Policy (Broker/Employer) – English (PDF)
• Chiropractic Care Flyer – English (PDF)
• Tools to Help You Compare Hospitals in Your Area – English (PDF)

National PPO Network (Out-of-State PPO)

• Broker Cigna Healthcare PPO Network FAQ – English (PDF)
• Cigna Healthcare PPO Member Guide – English (PDF)
• Member Cigna Healthcare PPO Network FAQ – English (PDF)
• Member Cigna Healthcare PPO Network FAQ – En Español (Spanish) (PDF)

Additional Member/Prospect Materials

• Health Net Beginnings – English (PDF)
• Health Net Beginnings – En Español (Spanish) (PDF)
• LGBTQ+ Benefits Flyer – English (PDF)
• LGBTQ+ Benefits Flyer – En Español (Spanish) (PDF)
• HealthNet.com Flyer – English (PDF)
• HealthNet.com Flyer – En Español (Spanish) (PDF)
• HealthNet.com Plus Flyer – English (PDF)
• HealthNet.com Plus Flyer – En Español (Spanish) (PDF)
• ProviderSearch Information – English (PDF)
• ProviderSearch Information – En Español (Spanish) (PDF)
• HMO Flu Shot Flyer – English (PDF)
• HMO Flu Shot Flyer – En Español (Spanish) (PDF)
• Preventive Care Services Overview (ACA Non-Grandfathered Plans) – English (PDF)
• Preventive Care Services Overview (ACA Non-Grandfathered Plans) – En Español (Spanish) (PDF)
• Your Cardiovascular Health is Key to a Healthy Life (PDF)
• 2025 HSA-compatible PPO Member Brochure – English (PDF)

Behavioral Health

• Behavioral Health Guide – English (PDF)
• Behavioral Health Guide – En Español (Spanish) (PDF)
• Children's Anxiety Flyer – English (PDF)
• Protect Your Child's Physical and Mental Well Being (PDF)

Employer Materials

• Information for Small Business Groups – English (PDF)
• Small Group Employer Guide – English (PDF)
• Let Your Broker Help You Manage Your Account – English (PDF)
• HSA Employer flyer – English (PDF)

Glossaries

• Uniform Glossary of Health Coverage and Medical Terms – English (PDF)
• Uniform Glossary of Health Coverage and Medical Terms – En Español (Spanish) (PDF)
• Uniform Glossary of Health Coverage and Medical Terms – (Chinese) (PDF)
• Uniform Glossary of Health Coverage and Medical Terms – Navajo (PDF)
• Uniform Glossary of Health Coverage and Medical Terms – (Korean) (PDF)

Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.

• Employer Group Pharmacy Benefit Member Guide – English (PDF)
• Guía de Beneficios de Farmacia para Afiliados – En Español (Spanish) (PDF)
• Mail Service Pharmacy™ and Maintenance Choice^® Program – English (PDF)
• Mail Service Pharmacy™ and Maintenance Choice^® Program – En Español (Spanish) (PDF)
• Information on Free Blood Glucose Meters – English (PDF)
• Take Medications the Right Way – English (PDF)
• Generic vs Brand-Name Drugs Information – English (PDF)
• Prescription Drug Claim Form – English (PDF)
• Prescription Drug Claim Form – En Español (Spanish) (PDF)
• Prescription Transition form – English (PDF)
• Prescription Transition form – En Español (Spanish) (PDF)
• Getting Started With Mail Order Pharmacy Kit – English (PDF)
• Getting Started With Mail Order Pharmacy Kit – En Español (Spanish) (PDF)
• Home Infusion Fact Sheet – English (PDF)

• Ancillary Product Guide – 2025 – English (PDF)
• Ancillary Product Guide – 2024 – English (PDF)
• Ancillary Sell Sheet – 2025 – English (PDF)
• Ancillary Sell Sheet – 2024 – English (PDF)
• Pediatric Dental/Vision (HMO) – English (PDF)
• Pediatric Dental/Vision (PPO) – English (PDF)

Dental Materials

• Dental Provider Search Flyer – English (PDF)
• Your Dental Website (member) – English (PDF)

Vision Materials

• Vision Website (member) – English (PDF)

Health Net Life

These forms are customizable to allow for the addition of benefit level.

• Basic Life Insurance with AD&D – English (PDF)
• Basic Life Insurance no AD&D – English (PDF)

Travel Guides

• HMO Travel Guide – English (PDF)
• HMO Travel Guide – En Español (Spanish) (PDF)

Members can download claim forms at Health Net. Claim forms can also be found under the Applications and Forms section on this page.

• PPO Travel Guide – English (PDF)
• PPO Travel Guide – En Español (Spanish) (PDF)

Members can download claim forms at Health Net. Claim forms can also be found under the Applications and Forms section on this page.

Additional Materials

• Understanding your Explanation of Benefits (EOB) – English/Spanish (PDF)
• Understanding Your Billing Statement – English (PDF)

• FlexSystem Highlights Overview – English (PDF)
• FlexSystem Premium Only Plan (POP) Information Sheet – English (PDF)
• Premium Only Plan Marketing Manual – English (PDF)

Dental – HMO

• Dental – HMO – Health Net Plus 150 – Plan Overview – English (PDF)
• Dental – HMO – Health Net Plus 150 – Plan Overview – En Español (Spanish) (PDF)
• Dental – HMO – Health Net Plus 150 – Schedule of Benefits – English (PDF)
• Dental – HMO – Health Net Plus 225 – Plan Overview – English (PDF)
• Dental – HMO – Health Net Plus 225 – Plan Overview – En Español (Spanish) (PDF)
• Dental – HMO – Health Net Plus 225 – Schedule of Benefits – English (PDF)

Dental – PPO

• Dental – PPO – Classic 4 1500 – English (PDF)
• Dental – PPO – Classic 4 1500 – En Español (Spanish) (PDF)
• Dental – PPO – Classic 5 1500 – English (PDF)
• Dental – PPO – Classic 5 1500 – En Español (Spanish) (PDF)
• Dental – PPO – Classic 5 1500 – English (PDF)
• Dental – PPO – Classic 5 1500 – En Español (Spanish) (PDF)
• Dental – PPO – Classic 7 Unlimited – English (PDF)
• Dental – PPO – Classic 7 Unlimited – En Español (Spanish) (PDF)
• Dental – PPO – Classic 11 Unlimited – English (PDF)
• Dental – PPO – Classic 11 Unlimited – En Español (Spanish) (PDF)
• Dental – PPO – Essential 2 1000 – English (PDF)
• Dental – PPO – Essential 2 1000 – En Español (Spanish) (PDF)
• Dental – PPO – Essential 5 1500 – English (PDF)
• Dental – PPO – Essential 5 1500 – En Español (Spanish) (PDF)
• Dental – PPO – Essential 6 1500 – English (PDF)
• Dental – PPO – Essential 6 1500 – En Español (Spanish) (PDF)
• Dental – PPO – Essential 9 3000 – English (PDF)
• Dental – PPO – Essential 9 3000 – En Español (Spanish) (PDF)

Vision Plans

• Vision Plans – Exam Only – English (PDF)
• Vision Plans – Elite 1010-1 – English (PDF)
• Vision Plans – Plus 20-1 – English (PDF)
• Vision Plans – Preferred 1025-2 – English (PDF)
• Vision Plans – Preferred 1025-3 – English (PDF)
• Vision Plans – Preferred 1025-3 – En Español (Spanish) (PDF)
• Vision Plans – Preferred Value 10-3 – English (PDF)
• Vision Plans – Supreme 010-2 – English (PDF)

Dental – HMO

• Dental – HMO – Health Net Plus 150 – Plan Overview – English (PDF)
• Dental – HMO – Health Net Plus 150 – Plan Overview – En Español (Spanish) (PDF)
• Dental – HMO – Health Net Plus 150 – Schedule of Benefits – English (PDF)
• Dental – HMO – Health Net Plus 225 – Plan Overview – English (PDF)
• Dental – HMO – Health Net Plus 225 – Plan Overview – En Español (Spanish) (PDF)
• Dental – HMO – Health Net Plus 225 – Schedule of Benefits – English (PDF)

Dental – PPO

• Dental – PPO – Classic 4 1500 – English (PDF)
• Dental – PPO – Classic 4 1500 – En Español (Spanish) (PDF)
• Dental – PPO – Classic 5 1500 – English (PDF)
• Dental – PPO – Classic 5 1500 – En Español (Spanish) (PDF)
• Dental – PPO – Essential 2 1000 – English (PDF)
• Dental – PPO – Essential 2 1000 – En Español (Spanish) (PDF)
• Dental – PPO – Essential 5 1500 – English (PDF)
• Dental – PPO – Essential 5 1500 – En Español (Spanish) (PDF)
• Dental – PPO – Essential 6 1500 – English (PDF)
• Dental – PPO – Essential 6 1500 – En Español (Spanish) (PDF)

Vision Plans

• Vision Plans – Exam Only – English (PDF)
• Vision Plans – Elite 1010-1 – English (PDF)
• Vision Plans – Plus 20-1 – English (PDF)
• Vision Plans – Preferred 1025-2 – English (PDF)
• Vision Plans – Preferred 1025-3 – English (PDF)
• Vision Plans – Preferred Value 10-3 – English (PDF)
• Vision Plans – Supreme 010-2 – English (PDF)

• CA Wellness Member Brochure – English (PDF)
• CA Wellness Member Brochure – En Español (Spanish) (PDF)
• Healthy Discounts Member Flyer – English (PDF)
• Healthy Discounts Member Flyer – En Español (Spanish) (PDF)
• myStrength Program Flyer – English (PDF)
• myStrength Program Flyer – En Español (Spanish) (PDF)
• Active&Fit™ Direct Program Flyer – English (PDF)
• Sharecare Unwinding Flyer – English (PDF)
• Sharecare Unwinding FAQs – English (PDF)
• Sharecare Eat Right Now Program Flyer – English (PDF)
• Sharecare Eat Right Now FAQs – English (PDF)
• Sharecare FAQs – English (PDF)
• Sharecare Craving to Quit – English (PDF)
• Sharecare Health Coaching (Lifestyle Management Flyer) – English (PDF)
• Sharecare Health Coaching (Lifestyle Management FAQs) – English (PDF)
• Sharecare Green Day Overview – English (PDF)
• Sharecare How to Link Trackers Guide – English (PDF)
• Sharecare RealAge Program Overview – English (PDF)
• Sharecare RealAge Program FAQs – English (PDF)
• Teladoc Health Member FAQs – English (PDF)
• Teladoc Health Member FAQs – En Español (Spanish) (PDF)
• Teladoc Health Member Flyer – English (PDF)
• Teladoc Health Member Flyer – En Español (Spanish) (PDF)
• Teladoc Mental Health Flyer – English (PDF)
• Tips to Stop Smoking – English & Spanish (PDF)
• Wellness Tools – English (PDF)
• Wellness Tools – En Español (Spanish) (PDF)
• 2024 Wellness Webinar Flyer – English (PDF)
• 2024 Wellness Webinar Flyer – En Español (Spanish) (PDF)

Broker / Employer Materials

• Wellness Employer Broker Toolkit – English (PDF)
• Healthy Discounts Member Flyer – English (PDF)
• Healthy Discounts Member Flyer – En Español (Spanish) (PDF)
• National Observances Calendar for Employers – English (PDF)
• Preventive Screening Guidelines – English (PDF)
• Preventive Screening Guidelines – En Español (Spanish) (PDF)
• Wellness Rewards Program FAQs for Employers – English (PDF)
• 2024 Wellness Webinar Flyer – English (PDF)
• 2024 Wellness Webinar Flyer – En Español (Spanish) (PDF)

• Broker -- Salud HMO y Más flyer 2025 – English (PDF)
• Broker – Salud HMO y Más flyer 2024 – English (PDF)
• Salud HMO y Más Brochure 2025 – English (PDF)
• Salud HMO y Más Brochure 2025 – En Español (Spanish) (PDF)
• Salud HMO y Más Brochure 2024 – English (PDF)
• Salud HMO y Más Brochure 2024 – En Español (Spanish) (PDF)
• Broker/Employer – Salud HMO y Más/Scripps Health Flyer – English (PDF)

Refer to County Reference Quick Guide to determine service areas in each directory. Other reference quick guides coming soon – Northern California, Orange, Riverside, San Bernardino.

• Tailored Networks Comparison Lists – Northern California – English (PDF)
• Tailored Networks Comparison Lists – Central California – English (PDF)
• Tailored Networks Comparison Lists – Los Angeles County – English (PDF)
• Tailored Networks Comparison Lists – Orange County – English (PDF)
• Tailored Networks Comparison Lists – Riverside County – English (PDF)
• Tailored Networks Comparison Lists – San Bernardino County – English (PDF)
• Tailored Networks Comparison Lists – San Diego County – English (PDF)
• How Soon Can I See the Doctor – English (PDF)
• How Soon Can I See the Doctor – En Español (Spanish) (PDF)
• ProviderSearch Information – English (PDF)
• ProviderSearch Information – En Español (Spanish) (PDF)

Provider Directories

If you are looking for a participating provider, please use ProviderSearch.