Get Health Alliance Small Group Employer Application 2018-2025

Filling out the Health Alliance Small Group Employer Application online can be a straightforward process when you have the right guidance. This guide will provide you with step-by-step instructions to help you complete the application accurately and efficiently.

Follow the steps to complete your application with ease.

1. Click ‘Get Form’ button to access the Health Alliance Small Group Employer Application and open it in your chosen editor.
2. Begin by entering the group name exactly as it appears on your tax and wage statement. This ensures consistency with official records.
3. Input your Employer Federal Tax ID Number (TIN) in the designated field. This number is critical for tax purposes and must be accurate.
4. Fill out the group contact information including name, industry type, email address, physical address, billing address, city, state, phone number, fax number, and zip code.
5. In Section 1, provide additional group information, starting with the total number of employees. Include full-time, part-time, seasonal workers, and owners.
6. State the requested effective date for Health Alliance Northwest. Then, indicate the name of your current insurance carrier.
7. Answer whether Health Alliance Northwest is your sole source of health insurance by selecting Yes or No. If No, list the other carriers.
8. Enter the date your business was established and select your organization's type from the available options.
9. Indicate if your organization is subject to ERISA by selecting Yes or No.
10. Move on to Section 2 for Medicare Services. Here, you can express interest in a Medicare Advantage plan and provide relevant details.
11. Inquire about the number of Medicare-Eligible employees and retirees, and choose a Medicare billing type.
12. Provide the Medicare plan contact information as requested, filling out the email address, physical address, city, state, zip code, billing address, phone number, and fax number.
13. In Section 3, note if you have a Health Savings Account (HSA) and if you have a Health Reimbursement Arrangement (HRA).
14. If applicable, fill out Section 4 with broker information, ensuring the broker's name, agency, signature, and date are provided.
15. In Section 5, attest to the accuracy of the information provided by entering the group contact name, signature, and date.
16. Review all entries for accuracy and completeness. Once satisfied, save your changes, and you may have the option to download, print, or share the completed form.

Complete your Health Alliance Small Group Employer Application online today for a smooth and efficient process.