Forms and Applications

My Advance Care Plan (Form)

My Advance Care Planning Guide

Agent of Record - Change Request

Authorization for Use or Disclosure of Medical Information (Designated Representative)

Authorization to Release/Obtain PHI

Revocation of Authorization Form

Personal Health Information (PHI) Restriction Form

Medicaid Primary Care Provider (PCP) Change Request

Formulario de solicitud de cambio de proveedor de atención primaria (PCP)

Disabled Dependent Certification Form

Formulario de Certificación de Dependiente Discapacitado

Confidentiality Agreement and Portal User Profile Form

Coordination of Benefits - Employers

Broker/Agent Electronic Payment Authorization Agreement

Application for Individual Health Coverage 2025

Application for Individual Health Coverage 2024

Application for Individual Health Coverage 2024 (en Español)

Sentara Equity/HSA Health Savings Account Enrollment Form

BusinessEDGE® Enrollment Application 5-250 Member 2024

BusinessEDGE® Enrollment Application 5-250 Member 2024 (en Español)

Group Auto Debit Withdrawal BusinessEDGE

Group BusinessEDGE Enrollment Application

BusinessEDGE® Medical Risk Form

BusinessEDGE Quoting Spreadsheet

New Business Enrollment Spreadsheet

2025 Small Group Employer Application

Small Group Enrollment Application 1-50 Member 2025

Small Group Enrollment Application 1-50 Member 2024

Small Group Enrollment Application 1-50 Member 2024 (en Español)

2024 Small Group Employer Application

Small Group Quoting Spreadsheet

New Business Enrollment Spreadsheet

Group Auto Debit Form

Enrollment Application Mid Group Health Questionnaire

2024 Mid Market Group Application

Mid-Market Enrollment Application 51-150 Member 2024

Mid-Market Enrollment Application 51-150 Member 2024 (en Español)

Mid-Market Enrollment Application 51-150 Member 2023

Enrollment Application Employee Health Questionnaire 2024

Enrollment Application Employee Health Questionnaire 2023

Enrollment Application Small/Mid Group Medical History Form

Mid-Market Quoting Spreadsheet

GRx Census Template

New Business Enrollment Spreadsheet

Group Auto Debit Form

Open Enrollment Spreadsheet

1099 Eligibility and Attestation Form

HIPAA Agreement

Commercial Member Complaint Packet

Commercial Member Appeals Packet

Self-Funded Appeal Packet

Out-of-Area Dependent Child Form — for members enrolled in the Out-of-Area Dependent Program

Out-of-Area Dependent Child Form — for members whose employer has purchased the Out-of-Area dependent rider

Prescription Drug Claim Form

Transitioning Care to Sentara Health Plans

Virginia Small Employer COBRA