Fax Cover Enrollment Transaction Authorization
Need to make an enrollment change? Use this cover sheet and fax your request to us at (877)-464-0167
Company Census Form
Use this form to give us your employee information. This is an updated form for the 2014 ACA compliant plans. Please note that under the ACA we must collect dependent data such as date of birth and also tobacco user status of all members. The more accurate the information is, the more accurate your quotes will be! This can also be faxed to us at our secure fax (877)464-0167.
Physician Census List
Thinking about changing insurers but you’re unsure about the doctors in your proposed plan? Use this form to tell us which doctors, facilities or hospitals you want us to search for, and we will do a network comparison and a cross network analysis. Just complete and fax the form to us at (877)464-0167
EXCHANGE NOTICE-FOR EMPLOYERS OFFERING COVERAGE
All employers are required to notify current and new employees about the new health insurance “exchanges” or marketplaces by October 1st and annually thereafter. This form will make this task easier for you.
EXCHANGE NOTICE-FOR EMPLOYERS NOT OFFERING COVERAGE
All employers are required to notify current and new employees about the new health insurance “exchanges” or marketplaces by October 1st 2013 and annually thereafter. This form will make this task easier for you. This form is specifically worded for employers who will no longer, or currently do not, offer employer paid coverage.
COBRA information and forms are available here.
Looking for PA Mini-Cobra information and notices? click here
Heathcare Reform…more forms click here
Group Enrollment Forms
Independence Blue Cross
IBC Small Group Employee Enrollment Form
For employees being added to a small group
IBC Proof of Eligibility Form
For employees being added to a small group who are not on payrolls such as officers and owners
Individual Client Forms
Getting enrolled Total Benefit Solutions Inc has designed a custom form for our clients to use for enrolling on the health insurance marketplace. Using this form and submitting it to Total Benefit Solutions Inc will enable our Marketplace trained and certified licensed independent brokers to assist you in the enrollment process from the registration right through the enrollment! Remember as your independent broker we always work in your best interests, not an insurance company. We represent you, our client and not an insurer or government agency.
Click the link below to open the form and get started! When completed, just click the link to attach it to an email, or print and fax it to our toll free secure fax at 1 (877)464-0167. It couldn’t get any easier!
Medicare Client Forms
Click Here to Download the Scope of Appointment Form The Scope of Appointment form is required by CMS. Your Total Benefits Representative will ask you to return the form via our secure fax at 888-287-3186 or e-mail. in order to assist you properly. You may download and print the form, or complete it online.
Needs Assessment Survey This form can be completed before your meeting. It can be faxed back along with the scope of appointment if you want. The form will help you determine what your needs are when planning for the upcoming year. NEADS_Assessment_Survey
Looking for Healthcare Reform related forms? Click here.