Price Associates Insurance Services, Inc.
Providing Exemplary Service to Agents for Over 30 years.
CaliforniaChoice Small Group Downloads
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Applications & Forms Form # Effective
Affidavit of Domestic Partnership  CC 0554  02/08
Affidavit of Domestic Partnership (Spanish)  CC0554SP  02/08
Agent Agreement  CA 0130  03/06
Agent Agreement - AIG Dental  NA  09/02
Blue Shield Express Scripts Order Form  A11886  10/03
Blue Shield Medical Claim Form  CLM-14850  12/00
Blue Shield Prescription Claim Form  C-14352  10/03
Broker Licensing Form  CA 0100  01/08
Case Submission Acknowledgement Form  CC0555  04/07
Case Submission Acknowledgment  CC 055  04/07
Case Submission Checklist  CC0261  10/06
Change of Medical Coverage (Spanish)  PL 0311SP A  02/08
Change Request Form  CC 0500B  08/07
Change Request Form - Employee (Spanish)  CC0500SP  01/07
Change Request Form (Spanish)  CC 0500SP  08/07
Change Request Form (Spanish)  CC 0311SP B  01/08
Change Request Form EE  CC 0311B  01/08
COBRA Enrollment Application  CC 0600A  08/07
COBRA Participant Cancelation Notification  CC 0425  11/07
Common Ownership Statement  CC 0553  07/05
Confirmation of Eligibility  CC 0562  04/07
Direct Deposit Authorization  CA 5218  06/06
Domestic Partner Affidavit (Spanish)  CC 0554SP  04/07
EE Enrollment Guide  CC0300  01/07
Employee Aplication  CC0310  01/07
Employee Aplication  CC 310  03/07
Employee Aplication (For groups enrolling or renewing for an effective date of 7/1/07 thru 12/1/07)  CC 0310  07/07
Employee Aplication (Spanish) (For groups enrolling or renewing for an effective date of 7/1/07 through 12/1/07)  CC 0315  07/07
Employee Application  CC 0312  01/08
EMPLOYEE APPLICATION (7/1/07 thru 12/1/07)  CC 0310  04/07
EMPLOYEE APPLICATION (7/1/07 thru 12/1/07) (Spanish)  CC 0315  04/07
Employee Application (Spanish)  CC 0312  01/08
Employee Application (Spanish)  PL 0310SP B  02/08
Employee Health Questionnaire  CC0568  10/05
Employee Health Questionnaire (Spanish)  CC568SP  08/06
Employer Application  CC0201C  01/08
EMPLOYER APPLICATION (For groups enrolling or renewing for an effective date of 7/1/07 through 12/1/07)  CC 0201  07/07
Employer Change Request Form  CC 0564  09/06
Employer Change Request Form  CC 0564A  08/07
Employer's Legal Responsibility Regarding COBRA Coverage  CC 0552  04/07
Enrollment Application  CC 0310  09/06
Full Time Student Verification Form  CC0206  11/06
Group Eligibility Recertification - Employer Notification  CC3611  03/07
Group Eligibility Recertification - Employer Notification  CC3611  03/07
Health Net Medical Claim Form  13414  11/02
Health Net Prescription Claim Form  10882  10/01
Health Questionaire (Spanish)  CC0568  04/07
HEALTH QUESTIONNAIRE  CC 0568  04/07
HEALTH QUESTIONNAIRE (Spanish)  CC 0568SP  04/07
Kaiser Permanente Emergency Medical Claim Form  98700  04/04
New Hire Enrollment Quote Request  CC 0170  10/06
Open Enrollment Change Request - Employee  CC 0311  03/07
Open Enrollment Change Request Form  CC 0311  10/06
Open Enrollment Change Request Form - Employee (Spanish)  CC0311SP  01/07
Open Enrollment Change Request Form (Employee)  CC0311  01/07
Open Enrollment Change Request Form (Spanish)  CC 0311SP  08/07
Owner / Partner  CC 0202  07/06
Owner / Partner Statement  CC0202  12/06
Prior Carrier Cancellation  CC 0557  11/01
Proposal Request  CC 0120A  02/04
Renewal Change Request Form  PL 0311A  02/08
Salud Y Mas HMO & Salud Mexico  CC 0194  01/07
Salud-Mexico Application & Brochure (Spanish)  CC0194  01/08
Security Financial Life Claim Form  GG-3017B  04/02
Security Financial Life Claim Procedures  GG-3017A  04/02
Small Group Disclosure  CC 240  03/07
Small Group Qualification  CC 0559  04/03
Student Verification  CC 0206  11/03
Western Health Advantage RX Claim Form  C300  02/01
Benefits & Guides Form # Effective
Broker Disclosure Information Sheet  CC 0160  04/07
Business Associate Agreement  CA0125B  08/07
ChiroPlus Provider Directory  NA  12/07
Chiropractic / Acupuncture  CC 0294  10/06
Chiropractic / Acupuncture Benefit Sheet  CC0294  10/06
Choice Brochure  cc0190  01/08
Choice Brochure (For groups enrolling or renewing for an effective date of 7/1/07 through 12/1/07)  CC 0190  10/07
Consumer Directed Plans Summary  CC5234C  01/08
Define Contribution Workbook  CC 0225  04/04
Disabled Dependent Certification  CC 0440  09/01
Employee Enrollment Guide  CC0300  10/06
Employee Optional Benefits Guide  CC320  01/07
Employee Optional Dental Benefits Guide  CC0320  01/07
Employer Disclosure  CC 0250  11/03
Exciting News for January 1, 2007!  CC 5336V2  10/06
Formulary Guide (1.1.06 - 6.1.06)  CC 5121  01/06
Formulary Guide (7.1.05 - 12.1.05)  CC 5121  05/05
Health Net Open Elect Access Brochure  CC 5210  10/03
Health Net Rx by Mail  6008955  02/05
Health Plan and Formulary Guide  CC5008  01/08
Optional Benefits for Employers  CC 0220  01/07
Optional Benefits for Employers  CC0220  01/08
Privacy Statement  CA 0125  03/06
Producer Guidelines  CC 5233  10/06
Producer Guidelines  CC5233  02/07
Program Highlights  CC 5356  10/06
Program Highlights  CC5356  01/08
Program Highlights for Employers with 2-50 Employees  CC5356(V2)  02/07
Recertification Checklist  CC3611F  04/07
Small Group (2-50) Case Submission Checklist  CC 0261  04/07
Small Group Disclosure  CC 0240  09/06
Small Group Disclosure  CC0240  01/07
Submission Checklist  CC0261  08/07
Underwriting Guidelines  CC 6009  09/07
Underwriting Guidelines  CC6009  01/08
Dental Form # Effective
Dental - Employee Benefits Guide  CC 0320  11/05
Dental 100 Brochure  CC0270  01/08
Dental 100 Brochure (Spanish)  CC0270SP  12/07
Dental 100 Copay Guide  CC0271  01/08
Dental 100 Provider List - FDH  6843  07/05
Dental 3500 Provider List - FDH  410  07/05
Dental 4000/5000 Provider List - FDH  7735  07/05
Dental Buy-Up Application - Inforce Group  CC 0566  10/06
Dental Claim Form (AIG)  00303401-1132  06/04
Dental Flyer  CC0015A  01/07
Dental Plans Flyer  CC 0015a  10/06
Dental Provider Directory - FDH CA (EPO/PPO Plans)  NA  05/03
Dental Provider List - SmileSaver 1000/3000  CC 5287  09/04
Optional Dental Benefits for Employees  CC0320  01/08
HMO Form # Effective
EMPLOYEE HMO ENROLLMENT GUIDE (Spanish)  CC 0306  04/07
EMPLOYEE HMO/PPO ENROLLMENT GUIDE (7/1/07 thru 12/1/07)  CC 0300  04/07
HMO Benefit Guide - Employer (Spanish)  CC 0306  09/06
HMOs Benefit Summaries  CC5234A  01/08
HSA Form # Effective
HSA - Qualified Plans  CC0015D  01/08
HSA Brochure  CC 0522  06/06
HSA Brochure  CC0522  06/06
PPO Form # Effective
Employee PPO Enrollment Guide (Spanish)  CC 0307  08/07
PPO 750  CC5336V2  06/06
PPO Benefit Guide (Spanish) 1/07 - 6/07  CC0307  01/07
PPOs Benefit Summaries  CC5234b  10/06
PPOs Benefit Summaries  CC5234B  01/08
Vision Form # Effective
Vision - Cole Provider Directory  CC 5287C  04/06
Vision Brochure  CC0280  08/07
Vision Brochure (Spanish)  CC0280SP  08/07
Vision Flyer  CC0015B  01/07
Vison Plans  CC 0015b  10/06
Voluntary Vision Application  CC 0285  10/06
Friday, May 09 2008 
License: 0596691
© 2008 Price Associates Insurance Services, Inc.