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Title | Download | State |
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Authorization for LifeMap to Release Information |
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AK, CA, ID, MT, OR, UT, WA, WY |
Individual Critical Illness Plus Application - ID |
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ID |
Individual Critical Illness Plus Application - OR |
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OR |
Individual Critical Illness Plus Application - WA |
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WA |
Individual Critical Illness Plus Beneficiary Form |
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ID, OR, UT, WA |
Individual Critical Illness Plus Enrollment Packet - UT |
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UT |
Individual Critical Illness Plus Flyer |
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OR, UT, WA |
Individual Critical Illness Plus Flyer - ID |
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ID |
Individual Dental Application - ID |
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ID |
Individual Dental Application - OR |
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OR |
Individual Dental Application - UT |
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UT |
Individual Dental Application - WA |
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WA |
Individual Dental Member Brochure - ID |
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ID |
Individual Dental Member Brochure - OR |
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OR |
Individual Dental Member Brochure - UT |
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UT |
Individual Dental Member Brochure - WA |
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WA |
Individual Dental Rates 1/1/2021 to 3/31/2021 - ID |
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ID |
Individual Dental Rates 1/1/2021 to 3/31/2021 - OR |
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OR |
Individual Dental Rates 1/1/2021 to 3/31/2021 - UT |
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UT |
Individual Dental Rates 1/1/2021 to 3/31/2021 - WA |
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WA |
Individual Dental Rates 4/1/2021 to 6/30/2021 - ID |
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ID |
Individual Dental Rates 4/1/2021 to 6/30/2021 - OR |
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OR |
Individual Dental Rates 4/1/2021 to 6/30/2021 - UT |
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UT |
Individual Dental Rates 4/1/2021 to 6/30/2021 - WA |
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WA |
Individual Short Term Medical Enrollment Packet - ID eff 9/1/2020 |
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ID |
Individual Short Term Medical Enrollment Packet - OR eff 1/1/2019 |
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OR |
Individual Short Term Medical Enrollment Packet - UT eff 1/1/2019 |
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UT |
Individual Short Term Medical Pharmacy Reimbursement Form |
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ID, OR, UT, WA |
Individual Short Term Medical Rates 1/1/2021 to 3/31/2021 - ID |
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ID |
Individual Short Term Medical Rates 1/1/2021 to 3/31/2021 - OR |
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OR |
Individual Short Term Medical Rates 1/1/2021 to 3/31/2021 - UT |
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UT |
Individual Short Term Medical Rates 4/1/2021 to 6/30/2021 - ID |
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ID |
Individual Short Term Medical Rates 4/1/2021 to 6/30/2021 - OR |
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OR |
Individual Vision Rider Reimbursement Form |
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ID, OR, UT |
Life Insurance Claim Form |
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AK, CA, ID, MT, OR, UT, WA, WY |
LifeMap Advantages Beltone ID Card |
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AK, CA, ID, MT, OR, UT, WA, WY |
LifeMap Advantages Member Flyer |
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AK, CA, ID, MT, OR, UT, WA, WY |
Notice of Privacy Practices - STM, Vision, Dental |
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AK, CA, ID, MT, OR, UT, WA, WY |
Privacy Notice |
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AK, CA, ID, MT, OR, UT, WA, WY |
STM Authorization For Use and Disclosure of Protected Health Information |
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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.
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