| Form | VA |
|---|---|
| Contract and Benefits Booklet Request Form | CUT6592 |
| Full-Time Equivalent (FTE) Group Size Calculation Worksheet | FRM6237 |
| Medicare Secondary Payer (MSP) Calculation Form | FRM4011 |
| Enrollment Transaction Report (ETR) | CUT5795 |
| Waiver of Enrollment | CUT6529 |
| Confirmation of Enrollment | CUT5801 |
| Disability Certification for Overaged Dependent | CUT5625 |
| Virginia Code Section | CUT5857 |
| Primary Caretaker Certification | N/A |
| COBRA Continuation | EOD5000 |
| Selection Form for Continuation of Group Coverage | EOD5005 |
| Virginia Point-of-Service Selection Form | CUT5620 |
| Affiliated Companies/Common Ownership Certification | CUT9069 |
| Proof of Prior Group Dental Coverage for Voluntary Dental | SUM1750 |
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BlueChoice HMO - Miscellaneous Forms - Virginia
Miscellaneous Forms - Virginia