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| Title | Download | State |
|---|---|---|
| Authorization for LifeMap to Release Information |
 Download PDF (179.09 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Individual Critical Illness and Emergency Treatment Benefit Claim Form |
Download PDF (877.17 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Individual Critical Illness Plus Application - ID |
Download PDF (857.59 KB) |
ID |
| Individual Critical Illness Plus Application - OR |
Download PDF (174.54 KB) |
OR |
| Individual Critical Illness Plus Application - WA |
Download PDF (1.03 MB) |
WA |
| Individual Critical Illness Plus Beneficiary Form |
Download PDF (83.93 KB) |
ID, OR, UT, WA |
| Individual Critical Illness Plus Enrollment Packet - UT |
Download PDF (723.12 KB) |
UT |
| Individual Critical Illness Plus Flyer |
Download PDF (112.64 KB) |
OR, UT, WA |
| Individual Critical Illness Plus Flyer - ID |
Download PDF (113.27 KB) |
ID |
| Individual Dental Enrollment Packet - ID |
Download PDF (914.11 KB) |
ID |
| Individual Dental Enrollment Packet - OR |
Download PDF (1.13 MB) |
OR |
| Individual Dental Enrollment Packet - UT |
Download PDF (921.42 KB) |
UT |
| Individual Dental Enrollment Packet - WA |
Download PDF (1.22 MB) |
WA |
| Individual Dental Member Brochure - ID |
Download PDF (193.48 KB) |
ID |
| Individual Dental Member Brochure - OR |
Download PDF (2.2 MB) |
OR |
| Individual Dental Member Brochure - UT |
Download PDF (193.42 KB) |
UT |
| Individual Dental Member Brochure - WA |
Download PDF (2.2 MB) |
WA |
| Individual Dental Rates 1/1/2022 to 3/31/2022 - ID |
Download PDF (327.65 KB) |
ID |
| Individual Dental Rates 1/1/2022 to 3/31/2022 - OR |
Download PDF (221.31 KB) |
OR |
| Individual Dental Rates 1/1/2022 to 3/31/2022 - UT |
Download PDF (333.42 KB) |
UT |
| Individual Dental Rates 1/1/2022 to 3/31/2022 - WA |
Download PDF (328.38 KB) |
WA |
| Individual Dental Rates 4/1/2022 to 6/30/2022 - ID |
Download PDF (122.49 KB) |
ID |
| Individual Dental Rates 4/1/2022 to 6/30/2022 - OR |
Download PDF (104.08 KB) |
OR |
| Individual Dental Rates 4/1/2022 to 6/30/2022 - UT |
Download PDF (134.44 KB) |
UT |
| Individual Dental Rates 4/1/2022 to 6/30/2022 - WA |
Download PDF (125.33 KB) |
WA |
| Individual Short Term Medical Enrollment Packet - ID |
Download PDF (324.86 KB) |
ID |
| Individual Short Term Medical Enrollment Packet - OR |
Download PDF (498.14 KB) |
OR |
| Individual Short Term Medical Enrollment Packet - WA |
Download PDF (491.59 KB) |
WA |
| Individual Short Term Medical Pharmacy Reimbursement Form |
Download PDF (32.81 KB) |
ID, OR, UT, WA |
| Individual Short Term Medical Rates 1/1/2022 to 3/31/2022 - ID |
Download PDF (168.19 KB) |
ID |
| Individual Short Term Medical Rates 1/1/2022 to 3/31/2022 - OR |
Download PDF (461.23 KB) |
OR |
| Individual Short Term Medical Rates 1/1/2022 to 3/31/2022 - WA |
Download PDF (464.55 KB) |
WA |
| Individual Vision Rider Reimbursement Form |
Download PDF (143.95 KB) |
ID, OR, UT |
| Life Insurance Claim Form |
Download PDF (284.21 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| LifeMap Advantages Beltone ID Card |
Download PDF (41.49 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| LifeMap Advantages Member Flyer |
Download PDF (885.84 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Notice of Privacy Practices - STM, Vision, Dental |
Download PDF (126.25 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Privacy Notice |
Download PDF (24.05 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| STM Authorization For Use and Disclosure of Protected Health Information |
Download PDF (129.8 KB) |
ID, OR, UT, WA |
Use this tool to help find the appropriate form. Simply select the audience that best fits you and the state you or your company resides in. If you are an employee covered under a group plan with LifeMap, you are a group plan member and don’t need to select a state. Feel free to reach out to us with any questions you have along the way.