HealthPass Member Forms

Information & Guidelines	HealthPass Summary of Benefits
	In-Network Only
Member Important Contacts Employer Handbook HealthPass Eligibility Guidelines Network Availability Pharmacy Options/Mail Order Employer Need To Know Guide Domestic Partner Registration Information Domestic Partner Alternative Affidavit Domestic Partner Declaration of Cohabitation and Financial Interdependence Guardian DMO and EverGuard Certificate of Coverage Guardian PPO and EverGuard Certificate of Coverage	HP Standard 15 HP Standard 20 GHI EPO 20 Plus GHI EPO 30 Plus GHI EPO 40 Plus Health Net EPO 25 Health Net EPO 30 HIP HMO 25 HP HIP HMO 5
	In & Out-of-Network
	HP Flexible 15 HP GHI PPO 30 GHI PPO 40 Plus Health Net POS 25-1000 Health Net POS 25-1500 HIP POS 25
Ancillary Products	Cost Sharing Plans
Guardian Managed DentalGuard Effective 1.01.08 Effective 2.01.08 - 1.01.09 Guardian DentalGuard Preferred Effective 1.01.08 Effective 2.01.08 - 1.01.09 EverGuard EverGuard Plus COBRA Health Advocate TaxSaver Information Sheet	GHI EPO Share 40 1k Plus GHI EPO Share 40 2k Plus Health Net EPO Share 25 HIP EPO 100/80 3k HIP EPO 100/90 New HIP PPO Share 30
Forms	HSA
Notice of Election 4th Qtr Enrollment Change Form 10.01.08 - 12.15.08 3rd Qtr Enrollment Change Form 7.01.08 - 9.15.08 2nd Qtr Enrollment Change Form .01.08 - 6.15.08 1st Qtr Enrollment Change Form1.01.08 - 3.15.08 PerfectHealth 1099 Eligibility Form Enrollment Checklist Employer - EFT Form EverGuard Late Enrollment Form Member Authorization Form Health Advocate Authorization Form GHI Student Verification Form HealthNet Student Verification Form HIP Student Verification Form Guardian Student Verification Form	GHI HSA EPO Index Health Net HSA POS 4500 PerfectHealth HSA EPO 2500D PerfectHealth HSA PPO 2500D PerfectHealth HSA PPO 5000D
	Available to existing groups only Health Net HMO 25 12.01.08 PerfectHealth PPO 2500P 7.01.09 PerfectHealth PPO 5000P 7.01.09 PerfectHealth EPO 2500P 7.01.09