Pacificare Small Group Forms Initial Enrollment Inforce Groups Claim Forms HIPAA Forms/Info Initial Enrollment Size Updated Small Group Enrollment Checklist PDF 2 pgs, 185k Aug 2004 Small Business Employer Group Application PDF 7 pgs, 712k Nov 2003 Sole Proprietor, Partner, or Corporate Officer Form PDF 1 pg, 66k Apr 2004 Workers' Compensation Exemption Statement PDF 1 pg, 95k Jul 2004 Employer Participation Agreement—Life Benefits PDF 5 pgs, 194k Jul 2004 Employee Enrollment and Declination of Coverage Form PDF 4 pgs, 70k Mar 2004 Employee Enrollment and Declination od Coverage Form (Spanish) PDF 4 pgs, 2104k Jan 2003 Small Business Individual Health Statement Application PDF 1 pg, 49k Sep 2003 Affidavit of Domestic Partnership PDF 1 pg, 37k Jul 2003 Group Acceptance/Change Application PDF 1 pg, 56k Nov 2003 Top Inforce Groups Size Updated Employee Enrollment and Declination of Coverage Form PDF 4 pgs, 70k Mar 2004 Employee Enrollment and Declination of Coverage Form (Spanish) PDF 4 pgs, 2104k Jan 2003 Change Request Form PDF 4 pgs, 530k Oct 2003 Employer Group Reporting Form PDF 1 pg, 43k Oct 2003 Full-Time Student Status Request Form PDF 1 pg, 44k Apr 2003 AB1401 Continuation COBRA Election Form PDF 1 pg, 48k Jun 2004 COBRA Election Form PDF 1 pg, 64k Apr 2004 Cal-COBRA Qualifying Event Notice Form PDF 1 pg, 60k Apr 2004 Top Claim Forms Size Updated Self-Directed Health Plan Medical Claim Form PDF 2 pgs, 61k Apr 2003 POS Medical Claim Form PDF 2 pgs, 33k July 2004 PPO Indemnity Medical Claim Form PDF 2 pgs, 89k Jan 2002 Prescription Drug Program Direct Member Reimbursement Form PDF 1 pg, 68k Mar 2001 Attending Dentist's Statement: Dental Claim Form PDF 2 pgs, 103k Oct 2003 Vision Claim Form PDF 1 pg, 33k Jul 2003 Top HIPAA Forms/Info Size Updated Authorization for Use or Disclosure of Health Information PDF 4 pgs, 224k July 2004 Back

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