Please note: The state field refers to the location where your employer is headquartered.

Title Download State
Authorization for LifeMap to Release Information PDF icon Download Form (179.09 KB) AK, CA, ID, MT, OR, UT, WA, WY
Individual Short Term Medical Enrollment Packet - ID PDF icon Download Form (324.86 KB) ID
Individual Short Term Medical Enrollment Packet - OR PDF icon Download Form (498.14 KB) OR
Individual Short Term Medical Enrollment Packet - WA PDF icon Download Form (491.59 KB) WA
Individual Short Term Medical Pharmacy Reimbursement Form PDF icon Download Form (32.81 KB) ID, OR, UT, WA
Individual Short Term Medical Rates 1/1/2022 to 3/31/2022 - ID PDF icon Download Form (168.19 KB) ID
Individual Short Term Medical Rates 1/1/2022 to 3/31/2022 - OR PDF icon Download Form (461.23 KB) OR
Individual Short Term Medical Rates 1/1/2022 to 3/31/2022 - WA PDF icon Download Form (464.55 KB) WA
Individual Short Term Medical Rates 10/1/2021 to 12/31/2021 - ID PDF icon Download Form (451.22 KB) ID
Individual Short Term Medical Rates 10/1/2021 to 12/31/2021 - OR PDF icon Download Form (459.83 KB) OR
Individual Short Term Medical Rates 10/1/2021 to 12/31/2021 - WA PDF icon Download Form (463.38 KB) WA
Notice of Privacy Practices - STM, Vision, Dental PDF icon Download Form (126.25 KB) AK, CA, ID, MT, OR, UT, WA, WY
Provider EFT Enrollment Form PDF icon Download Form (225.17 KB) AK, CA, ID, MT, OR, UT, WA, WY
STM Authorization For Use and Disclosure of Protected Health Information PDF icon Download Form (129.8 KB) ID, OR, UT, WA