Individual and Family

Broker Data Discrepancy Form

Use this form to provide information required to fulfill inquiry requests.

ID: CMC0008179 (06/16)

Broker-Of-Record Letter

This fillable form will generate a completed Broker-of-Record Letter.

ID: 32332 (W01/18)

Confirmation of HSA Selection

This provides confirmation of Health Savings Account (HSA) selection and summarizes account advantages.

ID: 5890 (W01/12)

IHC Enrollment Change Request Form

Use this form to help Individual & Family members enroll in or change their health plan.

ID: 744 With peds (W0922)

IHC Enrollment Change Request Form (Spanish)

This is a Spanish version of the Enrollment/Change form for Individuals and Families, to use when needed.

ID: 744 con Pediátrico (W0922)

Request To Have Medical Records Transferred

Members can complete this form and present to a physician, medical practice or institution to initiate a release or transfer of medical record information to another physician, medical practice or institution.

ID: 7953 (W06/16)

Special Enrollment Period Required Documentation

A detailed summary of the various documentation needed for individuals to establish Special Enrollment Period eligibility.

ID: CMC0008179 (06/16)