- 2019 CalCPA Subscription Agreement – Employer Application for all size firms – Your firm need only complete one subscription agreement regardless of how many group plans you elect.
- Employee Medical/Dental/Vision Enrollment form (For firms of 2 or more. All employees must complete the form. Employees waiving coverage must complete the waiver section.)
- Dental – Vision Enrollment Form (If enrolling in Dental and/or Vision only).
- Subscriber Change Form
- Medicare Secondary Payer (MSP) Statement (Applicable to firms with fewer than 20 employees)
- Group Term Life-LTD Enrollment Form (for groups of 2-9 only)
Groups with eligible employees can enroll online through the CalCPA Health enrollment area. This area offers group medical, dental, and vision plans – all available in one convenient enrollment process. Here you can get quotes on all the plans and choose the ones that best fit the needs of your firm. Once your firm submits its eligibility information and is approved to enroll, you can, at your discretion, allow your employees online access to enroll themselves and their family members.
Employer Notices - HIPAA
- HIPAA Privacy Notice
- Request for Access to Health Information
- Request for Confidential Communication of PHI
- Appointment of Personal Representative
- Request for Accounting of Disclosures
- Request for Amendment of Personal Health Information
- Request for Restriction on Use and Disclosure of PHI
- HIPAA Notification of Availability of Notice of Privacy Practices
HSA Forms and Information
For details call Banyan Administrators directly at 877.480.7923, CalCPAHealth@CalCPAHealth.com or have your broker contact CalCPA Health at 650.522.3251.
To learn more:
Express Scripts (ESI) Prescription Authorization/ Drug Forms
Express Scripts/Medco Forms (Express Scripts for CalCPA Health PPO and HSA Plans) (877) 659-5144
- Express Scripts Claim Form
- Express Scripts Mail Order Enrollment Form
- Express Scripts/Medco Allergy Questionnaire
- 2018 Formulary List – PPO (for the full list, please contact ESI Customer Service)
Express Scripts Forms (Express Scripts for CalCPA Health HMO Plans) (800) 700-7852