Forms

Enrollment Forms

  1. 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.
  2. 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.)
  3. Dental – Vision Enrollment Form (If enrolling in Dental and/or Vision only).
  4. Subscriber Change Form
  5. Medicare Secondary Payer (MSP) Statement (Applicable to firms with fewer than 20 employees)
  6. 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 - Health Care Reform

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:

Prescription Authorization

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 Forms (Express Scripts for CalCPA Health HMO Plans) (800) 700-7852

Have Questions?