APPLICATIONS & FORMS

The following is a list of our online forms and applications. Sales Literature can now be found under Sales Assistance To order a supply, use the Broker Supply Order Form. All Letter of Record forms can be found under Reports & Commissions.

online-fillable form Online-fillable form

Individual

2017 QHP

New applicants use the Idaho Individual Application & Cover Sheet for their region. To choose the correct application, please refer to the region by county list below. The QHP Change Form is used to change an existing member's off-exchange QHP plan. To choose the correct form, please refer to the region by county list below.

North Region - For residents of the following counties: Benewah, Bonner, Boundary, Clearwater, Idaho, Kootenai, Latah, Lewis, Nez Perce and Shoshone counties

Idaho Individual Application & Cover Sheet – North Region online-fillable form 3-1179
Qualified Health Plan Products Change Form – North Region online-fillable form 3-1182

Southwest Region - For residents of the following counties: Ada, Adams, Blaine, Boise, Camas, Canyon, Cassia, (for CarePoint St. Luke’s Health Partners plan applicants), Elmore, Gem, Gooding, Jerome, Lincoln, Minidoka, Owyhee, Payette, Twin Falls, Valley and Washington counties

Idaho Individual Application & Cover Sheet – SW Region online-fillable form 3-1180
Qualified Health Plan Products Change Form – SW Region online-fillable form 3-1183

East/Southeast Idaho Region - For residents of the following counties: Bannock, Bear Lake, Bingham, Bonneville, Butte, Caribou, Cassia (for Hometown East plan applicants), Clark, Custer, Franklin, Fremont, Jefferson, Lemhi, Madison, Minidoka, Oneida, Power and Teton counties

Idaho Individual Application & Cover Sheet – East/ SE Region online-fillable form 3-1178
Qualified Health Plan Products Change Form – East/ SE Region online-fillable form 3-1181

Grandfathered and Grandmothered

Idaho Individual Application IND-APP-11-2010  
Transfer Application 3-362

Medicare Supplement

2017 Idaho MedPlus Application online-fillable form 16-708
PERSI Authorization Form for Retiree Medicare Supplement Coverage online-fillable form 4-161
Authorization Agreement for Prearranged Payments 3-449

Short Term

Short Term PPO Application 3-614A
Spanish Short Term PPO Application 3-614A SP

Dental

Healthy Smiles Application 3-052a
Healthy Smiles Application - bilingual 3-052a-s
Individual QHP Dental Choice & Dental Choice Application 3-189A

General Maintenance Forms

Authorization Agreement for Automatic Withdrawal 3-449
Authorization to Delete Dependent  
Certification of Non-Use of Tobacco 3-319
Individual Letter of Record online-fillable form 3-037
SEP Validation Form (Validation of Qualifying Life Event)  
Residency Validation Form (Validation of Idaho residency)  
New applicants can apply using the Idaho Individual Application & Cover Sheet for their region. To choose the correct application please refer to to the region by county list below.
The QHP Change Form is used to change an existing member's off-exchange QHP plan. To choose the correct form, please refer to the region by county list below.

Group

Group Enrollment Applications

We've combined our coversheet and application into one PDF that can be used for all group sizes and both pre-ACA and post-ACA plans. We hope this makes the application process easier for you and your groups.

Idaho Universal Group Application online-fillable form

  • For all groups excluding the below

Idaho Universal Group Application with Health Statement online-fillable form

  • For all new medium  groups
  • For all new large groups not using claims experience
  • For existing small grandfathered/ grandmothered groups if enrollment addition exceeds 20% threshold
3-1157C
Group Standalone Dental Enrollment Application online-fillable form 3-395
Group Voluntary Vision Enrollment Application 3-412
Statewide School Retiree Application online-fillable form 4-150
Statewide Schools ASC Health/Dental/Vision Enrollment Application online-fillable form 3-307SWS

Other Group Forms

Small GroupLarge GroupForm DescriptionForm #
X   Employee Census Data 3-468
X   Employer Application & Questionnaire for New Small Group Coverage online-fillable form 3-549
X   Group Quoting System Excel Roster (.zip file)  
X   Universal Idaho Small Employer Application - Spanish online-fillable form 3-017S
X X Plan Change Form Multi Option Groups online-fillable form 3-128
X X Employee's Waiver of Health Care Coverage online-fillable form 3-467
X X Group Contact Change Form 3-1146
X X Group Letter of Record online-fillable form 3-302
X X SBC Attestation 3-325
X X Third Party COBRA Notification online-fillable form 3-1125
X X Probationary Period Waiver Request 3-183
  X Employer Application & Group Questionnaire for New Groups 51 or more Employees online-fillable form 3-550
  X Employer Application & Group Questionnaire for New ASC Groups online-fillable form 3-437
  X Private Exchange Application & Questionnaire for Mid & Large Groups online-fillable form 3-1208
  X Spanish - Idaho Large Employer Group Application & Cover Sheet online-fillable form 3-186S