| Form | VA |
|---|---|
| Request for Benefit Booklets | |
| Full-Time Equivalent (FTE) Group Size Calculation Worksheet | FRM4010 |
| Enrollment Transaction Report (ETR) | CUT5795 |
| Waiver of Enrollment | CUT6529 |
| Confirmation of Enrollment | CUT5801 |
| Disability Certification for Overaged Dependent | CUT5625 |
| Virginia Code Section | CUT5857 |
| Primary Care Certification | N/A |
| COBRA Continuation | EOD5000 |
| Selection Form for Continuation of Group Coverage |
Due to a planned data migration beginning Friday, July 11 at 11:00 p.m., and continuing through Monday, July 14 at 8:00 a.m., you may experience a delay in your information appearing on CareFirst portals. We expect that changes to member data will be reflected on the portals by Tuesday, July 15. Your patience is appreciated.
Change Healthcare notifying individuals of data breach. Learn more here.
Traditional - NCA Products Only - Miscellaneous Forms - Virginia
Miscellaneous Forms
Viewing and printing this document requires Microsoft Word.