Forms and Resources
For convenient access, download and print the forms and resources that you need.
Member Forms and Resources
- Grievance Form*
- Authorization for Use and Disclosure of Protected Health Information
- 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
2019: For plans effective 1/1/19 through 12/31/19
2018: For plans effective 1/1/18 through 12/31/18
General Forms
Employer Forms and Resources
2019: For plans effective 1/1/19 through 12/31/19
2018: For plans effective 1/1/18 through 12/31/18
General Forms
Provider Forms and Resources
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Additional Resources
Evidence of Coverage
2019 Individual and Family HMO Plans: For Plans Effective 1/1/19 Through 12/31/19
2019 Large Group HMO Plans: For Plans Effective 1/1/19 Through 12/31/19
2019 Small Group HMO Plans: For Plans Effective 1/1/19 Through 12/31/19
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
Summary of Benefits
2018 Small Group HMO Summary of Benefits: For Plans Effective 1/1/18 through 12/31/18
- Small Group SBC Platinum MS38 HMO
- Small Group SBC Platinum MS50 HMO
- Small Group SBC Platinum MS41 HMO
- Small Group SBC Gold MS37 HMO
- Small Group SBC Gold MS43 HMO
- Small Group SBC Gold MS42 HMO
- Small Group SBC Silver MS44 HMO
- Small Group SBC Silver SD17 HMO
- Small Group SBC Bronze MS46 HMO
- Small Group SBC Bronze SD08 HMO
2018 LARGE GROUP SBC HMO PLANS: FOR PLANS EFFECTIVE 1/1/18 THROUGH 12/31/18
- Large Group SBC Summit ML30 HMO
- Large Group SBC Summit ML31 HMO
- Large Group SBC Summit ML32 HMO
- Large Group SBC Summit ML34 HMO
- Large Group SBC Summit ML40 HMO
- Large Group SBC Summit ML50 HMO
- Large Group SBC Summit ML51 HMO
- Large Group SBC Peak ML19 HMO
- Large Group SBC Peak ML20 HMO
- Large Group SBC Peak ML21 HMO
- Large Group SBC Peak ML22 HMO
- Large Group SBC Peak ML24 HMO
- Large Group SBC Peak ML25 HMO
- Large Group SBC Ridge ML35 HMO
- Large Group SBC Ridge ML36 HMO
- Large Group SBC Ridge ML37 HMO
- Large Group SBC Vista HD11 HDHP HMO
- Large Group SBC Vista HD12 HDHP HMO
- Large Group SBC Vista HD13 HDHP HMO
- Large Group SBC Vista HD14 HDHP HMO
- Large Group SBC Vista HD16 HDHP HMO
2019 Small Group HMO Summary of Benefits: For Plans Effective 1/1/19 through 12/31/19
- Small Group SBC Platinum MS38 HMO
- Small Group SBC Platinum MS50 HMO
- Small Group SBC Platinum MS41 HMO
- Small Group SBC Gold MS47 HMO
- Small Group SBC Gold MS53 HMO
- Small Group SBC Gold MS42 HMO
- Small Group SBC Silver MS54 HMO
- Small Group SBC Silver SD27 HMO
- Small Group SBC Bronze MS56 HMO
- Small Group SBC Bronze SD18 HMO
2019 LARGE GROUP SBC HMO PLANS: FOR PLANS EFFECTIVE 1/1/19 THROUGH 12/31/19
- Large Group SBC Summit ML30 HMO
- Large Group SBC Summit ML31 HMO
- Large Group SBC Summit ML32 HMO
- Large Group SBC Summit ML34 HMO
- Large Group SBC Summit ML50 HMO
- Large Group SBC Summit ML51 HMO
- Large Group SBC Summit ML54 HMO
- Large Group SBC Peak ML19 HMO
- Large Group SBC Peak ML20 HMO
- Large Group SBC Peak ML21 HMO
- Large Group SBC Peak ML22 HMO
- Large Group SBC Peak ML24 HMO
- Large Group SBC Peak ML25 HMO
- Large Group SBC Ridge ML35 HMO
- Large Group SBC Ridge ML36 HMO
- Large Group SBC Ridge ML37 HMO
- Large Group SBC Vista HD11 HDHP HMO
- Large Group SBC Vista HD12 HDHP HMO
- Large Group SBC Vista HD13 HDHP HMO
- Large Group SBC Vista HD14 HDHP HMO
- Large Group SBC Vista HD16 HDHP HMO
2019 Individual and Family Plan Summary of Benefits: For Plans effective 1/1/19 through 12/31/19
Benefits and Coverage Matrix
2018 Small Group HMO Benefits and Coverage Matrix: For Plans effective 1/1/18 through 12/31/18
- Small Group BCM Platinum MS38 HMO
- Small Group BCM Platinum MS50 HMO
- Small Group BCM Platinum MS41 HMO
- Small Group BCM Gold MS37 HMO
- Small Group BCM Gold MS43 HMO
- Small Group BCM Gold MS42 HMO
- Small Group BCM Silver MS44 HMO
- Small Group BCM Silver SD17 HMO
- Small Group BCM Bronze MS46 HMO
- Small Group BCM Bronze SD08 HMO
2018 LARGE GROUP BCM HMO PLANS: FOR PLANS EFFECTIVE 1/1/18 THROUGH 12/31/18
- Large Group BCM Summit ML30 HMO
- Large Group BCM Summit ML31 HMO
- Large Group BCM Summit ML32 HMO
- Large Group BCM Summit ML34 HMO
- Large Group BCM Summit ML40 HMO
- Large Group BCM Summit ML50 HMO
- Large Group BCM Summit ML51 HMO
- Large Group BCM Peak ML19 HMO
- Large Group BCM Peak ML20 HMO
- Large Group BCM Peak ML21 HMO
- Large Group BCM Peak ML22 HMO
- Large Group BCM Peak ML24 HMO
- Large Group BCM Peak ML25 HMO
- Large Group BCM Ridge ML35 HMO
- Large Group BCM Ridge ML36 HMO
- Large Group BCM Ridge ML37 HMO
- Large Group BCM Vista HD11 HDHP HMO
- Large Group BCM Vista HD12 HDHP HMO
- Large Group BCM Vista HD13 HDHP HMO
- Large Group BCM Vista HD14 HDHP HMO
- Large Group BCM Vista HD16 HDHP HMO
2019 Small Group HMO Benefits and Coverage Matrix: For Plans effective 1/1/19 through 12/31/19
- Small Group BCM Platinum MS38 HMO
- Small Group BCM Platinum MS50 HMO
- Small Group BCM Platinum MS41 HMO
- Small Group BCM Gold MS47 HMO
- Small Group BCM Gold MS53 HMO
- Small Group BCM Gold MS42 HMO
- Small Group BCM Silver MS54 HMO
- Small Group BCM Silver SD27 HMO
- Small Group BCM Bronze MS56 HMO
- Small Group BCM Bronze SD18 HMO
2019 LARGE GROUP BCM HMO PLANS: FOR PLANS EFFECTIVE 1/1/19 THROUGH 12/31/19
- Large Group BCM Summit ML30 HMO
- Large Group BCM Summit ML31 HMO
- Large Group BCM Summit ML32 HMO
- Large Group BCM Summit ML34 HMO
- Large Group BCM Summit ML50 HMO
- Large Group BCM Summit ML51 HMO
- Large Group BCM Summit ML54 HMO
- Large Group BCM Peak ML19 HMO
- Large Group BCM Peak ML20 HMO
- Large Group BCM Peak ML21 HMO
- Large Group BCM Peak ML22 HMO
- Large Group BCM Peak ML24 HMO
- Large Group BCM Peak ML25 HMO
- Large Group BCM Ridge ML35 HMO
- Large Group BCM Ridge ML36 HMO
- Large Group BCM Ridge ML37 HMO
- Large Group BCM Vista HD11 HDHP HMO
- Large Group BCM Vista HD12 HDHP HMO
- Large Group BCM Vista HD13 HDHP HMO
- Large Group BCM Vista HD14 HDHP HMO
- Large Group BCM Vista HD16 HDHP HMO
2019 Individual and Family Plan Benefits and Coverage Matrix: For Plans effective 1/1/19 through 12/31/19
Sutter Health Plus Product Portfolio
2019 Product Portfolio
2018 Product Portfolio