Forms and Resources
For convenient access, download and print the forms and resources that you need.
Member Forms and Resources
- Grievance Form*
- Choosing a Primary Care Physician
- Continuity of Care Request Form*
- Coordination of Benefits Form
- Disabled Dependent Form
- Glossary of Terms
- Member Claim Form
- Member Rights and Responsibilities
- Pharmacy Mail Order Form
- Request for Review by DMHC Form*
- Request for Review by Sutter Health Plus Form*
- Right to Submit Request for Review of Cancellation, Recession or Nonrenewal of Your Plan Contract, Enrollment or Subscription*
- Timely Access Standards
- Uniform Glossary
Broker Forms and Resources
2018: For plans effective 1/1/18 through 12/31/18
- 2018 Individual and Family Plan Application and Enrollment
- 2018 Large Group Employer Application
- 2018 Large Group Enrollment Form
- 2018 Large Group Enrollment
- 2018 Small Group Employer Application
- 2018 Small Group Enrollment Form
- 2018 Large Group Underwriting Guidelines
- 2018 Small Group Underwriting Guidelines
2017: For plans effective 1/1/17 through 12/31/17
General Forms
Employer Forms and Resources
2018: For plans effective 1/1/18 through 12/31/18
2017: For plans effective 1/1/17 through 12/31/17
General Forms
Provider Forms and Resources
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Additional Resources
Evidence of Coverage
2018 Individual and Family HMO Plans: For Plans Effective 1/1/18 Through 12/31/18
2018 Large Group HMO Plans: For Plans Effective 1/1/18 Through 12/31/18
2018 Small Group HMO Plans: For Plans Effective 1/1/18 Through 12/31/18
2017 Individual and Family HMO Plans: For Plans Effective 1/1/17 Through 12/31/17
2017 Large Group HMO Plans: For Plans Effective 1/1/17 Through 12/31/17
2017 Small Group HMO Plans: For Plans Effective 1/1/17 Through 12/31/17
Summary of Benefits
2018 Small Group HMO Summary of Benefits: For Plans Effective 1/1/18 through 12/31/18
Benefits and Coverage Matrix
2018 Small Group HMO Benefits and Coverage Matrix: For Plans effective 1/1/18 through 12/31/18