1717 Central Avenue
Albany, NY 12205
Tel:
518-464-0400
Fax:
518-464-0404
info@epnevins.com
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Adult Dependent Eligibility Form
Agent/Broker-of-Record Appointment
Agent/Broker-of-Record Replacement Letter
Agreement for COBRA and New York Continuation of Benefits Premium Billing
Billing Agreement
Change/Termination/Reinstatement Worksheet Instructions
Dental Claim Form
Domestic Partner Enrollment Form
Employee Enrollment Form
Employer Online Services Delegation Form
Group Contract For HMO or Direct HMO
HIPPA Privacy Form
Medco Prescription Claim Form
Medical Benefits Claim Form
Member Enrollment/Change Form
New Business Affidavit Letter
New Employer Group Enrollment for Chambers/Associations and Payroll Administrators
Renewal Worksheet
Smal Group Recredentialing Form
Small Group Application/Change Form
Summary of Forms Required for Enrollment
Vision Claim Form
Wellpoint Rx Mail Order Form