Forms
English
- 1095-B Correction/Coverage Discrepancy Form
- Access to PHI Request Form
- Accounting of PHI Disclosures Request Form
- Amendment of PHI Request Form
- Chronic Care/Condition Management Referral Form
- Claim Reimbursement Form
- Confidential Communications Request
- Continuity of Care Form
- Declaration of Disability for Over Age Dependents
- Grievance Form
- HIPAA Use and Disclosure of Health Information
- HMO Help Center Complaint
- Individual Enrollment Application Form - Supplement
- Individual Termination Form
- Non-Registered Domestic Partner Form for Individual/Family Plans
- Notice of Language Assistance (NOLA)
- Privacy Complaint Form
- Rate Filing Disclosure Form - Individual
- Rate Filing Disclosure Form - Small Group
- Rate Filing Disclosure Form - Large Group
- Request for Termination Review Form
- Restriction to Use or Disclosure of PHI
Spanish
- 1095-B Correction/Coverage Discrepancy Form
- Access to PHI Request Form
- Accounting of PHI Disclosures Request Form
- Amendment of PHI Request Form
- Chronic Care/Condition Management Referral Form
- Confidential Communications Request
- Continuity of Care Form
- Declaration of Disability for Over Age Dependents
- Grievance Form
- HIPAA Use and Disclosure of Health Information
- HMO Help Center Complaint
- Individual Termination Form
- Non-Registered Domestic Partner Form for Individual/Family Plans
- Notice of Language Assistance (NOLA)
- Privacy Complaint Form
- Rate Filing Disclosure Form - Individual
- Rate Filing Disclosure Form - Small Group
- Rate Filing Disclosure Form - Large Group
- Request for Termination Review Form
- Restriction to Use or Disclosure of PHI
Downloads
We are currently enhancing the online renewal system. Please check back soon. For immediate assistance, contact a WHA Individual Plan Specialist at 888.563.2250 or individualsales@westernhealth.com.
This SBC is currently unavailable online.
For assistance, please contact WHA Sales as described below.
Call 888.563.2250 or email individualsales@westernhealth.com.
Este documento en español está siendo actualizado y no está disponible en línea. Por favor de, llamar a Servicio al Cliente 888.563.2250 para solicitar que se le envíe por correo.