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Forms

Minnesota medical plan forms
Western Wisconsin medical plan forms
Robin with HealthPartners (northeast Wisconsin) medical plan forms
North Dakota medical plan forms
South Dakota medical plan forms
HealthPartners UnityPoint Health (HPUPH – Iowa) medical plan forms
Dental plan forms
FSA and HRA forms

Minnesota medical plan forms

All group sizes

MN Controlled Group Form
Employee Change Form
Claim Form
Coordination of Benefits Claims Form
Medicare Secondary Payer Form
Agent of Record Assignment Form

Small employers

2019 MN Employer Application
2018 MN Employer Application
Small Employer Questionnaire for existing group changes
MN Small Group Affidavit of Ownership and Hours Worked
Tax Documentation Guidelines
Seasonal Industry Employee Agreement Form
Domestic Partnership Agreement and Affidavit
2019 MN/WI Employee Application or Mid-Year Hires
2018 MN/WI Employee Application or Mid-Year Hires

Large employers

Large Group Medical Proposal Request – combined
2019 MN Employer Application – Health History
2018 MN Non-Reform and EZ Employer Group Application
Employee Application – Health History
Employee Medical Enrollment Form

Western Wisconsin medical plan forms

All group sizes

WI Controlled Group Form
Employee Change Form
Claim Form
Coordination of Benefits Claims Form
Medicare Secondary Payer Form
Agent of Record Assignment Form

Small employers

2019 WI Employer Application
2018 WI Employer Application
Small Employer Questionnaire for existing group changes
WI Small Group Affidavit of Ownership and Hours Worked
Tax Documentation Guidelines
2019 MN/WI Employee Application or Mid-Year Hires
2018 MN/WI Employee Application or Mid-Year Hires
Employee Application_Non-ACA

Large employers

Large Group Medical Proposal Request – combined
2019 WI Employer Application – Health History
2018 WI Non-Reform and EZ Employer Group Application
Employee Application – Health History
Employee Medical Enrollment Form

Robin with HealthPartners (northeast Wisconsin) medical plan forms

All group sizes

Robin Controlled Group Form
Employee Change Form
Claim Form
Coordination of Benefits Claims Form
Medicare Secondary Payer Form
Agent of Record Assignment Form

Small employers

2019 Robin Employer Application
Small Employer Questionnaire for existing group changes
Robin Small Group Affidavit of Ownership and Hours Worked
2019 Robin Employee Application or Mid-Year Hires

Large employers

Robin Large Group Medical Proposal Request – combined
2019 Robin Employer Application – Health History
Robin Employee Application – Health History
Employee Medical Enrollment Form

North Dakota medical plan forms

Large employers

Large Group Medical Proposal Request – combined
2019 ND Employer Application – Health History
ND Controlled Group Form
Employee Application – Health History
Employee Medical Enrollment Form
Employee Change Form
Claim Form
Coordination of Benefits Claims Form
Medicare Secondary Payer Form
Agent of Record Assignment Form

South Dakota medical plan forms

Large employers

Large Group Medical Proposal Request – combined
2019 SD Employer Application – Health History
SD Controlled Group Form
Employee Application – Health History
Employee Medical Enrollment Form
Employee Change Form
Claim Form
Coordination of Benefits Claims Form
Medicare Secondary Payer Form
Agent of Record Assignment Form

HealthPartners UnityPoint Health (HPUPH – Iowa) medical plan forms

Large employers

HPUPH Large Group Medical Proposal Request – combined
2019 HPUPH Employer Application – Health History
HPUPH Controlled Group Form
HPUPH Employee Application – Health History
Employee Medical Enrollment Form
Employee Change Form
Claim Form
Coordination of Benefits Claims Form
Medicare Secondary Payer Form
Agent of Record Assignment Form

Dental plan forms

Dental MN Small Employer Application
Dental Enrollment Form_Open Access
Dental Enrollment Form_Dental Options
Dental Enrollment Form_Voluntary
Combined Medical/Dental Enrollment Form with waiting periods
Combined Medical/Dental Enrollment Form without waiting periods
Dental Coordination of Benefits Form

FSA and HRA forms

Flexible Spending Account Enrollment/Election Form
Direct Deposit Form
Automatic Claims Submission Opt Out Form
Mid-year Enrollment/Change Form
Letter of Medical Necessity
Health Care Expense Claim Form
Dependent Care Expense Claim Form
Transportation and Parking Expense Claim Form

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