This page gives you immediate access to Small Group Health Insurance Forms and Applications for California.
WESTERN HEALTH ADVANTAGE Forms & Applications For Small Groups - California
 
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Western Health Advantage Small Group Medical (2-50 employees)
Company
Group Medical - EMPLOYEE
Description
Form #
 Rev Date Fillable
Western Health Advantage
 Enrollment / Change Form For employees
WHA 211
9-09
  
Western Health Advantage
 Continuity of Care Request Form

If you are currently receiving treatment and (i) a new WHA member or (ii) an existing WHA member whose physician has terminated with WHA, you may request to temporarily remain with your existing physician.
WHA 219
11-08
  
Western Health Advantage
 Domestic Partner Form - Non Registered This form is used for employer groups that have agreed to cover non-registered domestic partners as dependents.
WHA 218
1-09
  
Western Health Advantage
 Health Information Release Form

Authorization for use or disclosure of health information.

     
Western Health Advantage
 Waiver of Coverage For declining coverage.  
9-02
  
Company
Group Medical - EMPLOYER
Description
Form #
Rev Date Fillable
Western Health Advantage
 Employer Group Application Form For employers
WHA 204
3-08
  
Western Health Advantage
 Sole Proprietor, Owner and Partner Statement Form    
2-09
  
Western Health Advantage
 Termination Form Complete to report member terminations to your account.
WHA 216
5-09
  
Company
Group Medical - OTHER
Description
Form #
Rev Date Fillable
Western Health Advantage
 Electronics Funds Transfer Authorization Form (EFT)    
12-08
  
Western Health Advantage
 Supply Requisition Form  
WHA 215
5-09