Group Forms
Cox HealthPlans has provided the following forms to assist you in the administration of your client’s group health plan.
Authorization for Release of Health Info - This form is used to designate those people allowed to receive information about your policy.
Certification of Employer Status - This form is used to verify group size.
Continuation of Coverage - This form is for an employer to notify Cox HealthPlans of a member’s election for State Continuation/COBRA coverage.
Coordination of Benefits - This form is used to verify if you or your enrolled dependents have other insurance coverage while insured with Cox HealthPlans.
Direct Payment - HMO - This form is used for group premium payments to be automatically deducted from your bank account.
Direct Payment - PPO - This form is used for group premium payments to be automatically deducted from your bank account.
Employee Enrollment - HMO - This form is used for enrolling a new employee, adding or terminating dependents, waiving coverage, address and names changes, and special enrollment in an HMO plan.
Employee Enrollment - PPO - This form is used for enrolling a new employee, adding or terminating dependents, waiving coverage, address and names changes, and special enrollment in an PPO plan.
Employee Termination - This form is used to remove an employee from the group health plan.
Employer Agreement and Group Application - HMO - This form is completed by a newly enrolled employer. It is also used for amendments to the HMO group contract.
Employer Agreement and Group Application - PPO - This form is completed by a newly enrolled employer. It is also used for amendments to the PPO group contract.
First Health Information/Service Area Map - This provides information regarding the Cox HealthPlans Service area, and access to First Health for nationwide PPO coverage.
Gatekeeper Checklist - Please see last page of employer application for the data required to submit gatekeeper underwriting.
Health Questionnaires (PPO) - These are used for underwriting purposes to obtain additional information regarding a specific health condition.
Independent Contractor - This form is used if an employer is requesting to add independent contractors to the group health policy.
Medical Claim - This form is used if a member needs to submit a medical claim.
Prescription Claim - This form is used if a member needs to submit a prescription claim.
Prescription Mail Order - This is the form used to request mail order service for prescription medications.
Prescription Prior Authorization - This form is used by a physician to request authorization of a particular prescription medication.
Self Referral - Care Management - This form is used to request assistance from our Medical Management Team.
If you have any questions or concerns, or need additional assistance, please contact the Cox HealthPlans Marketing Department at:
Phone 417.269.4679 or 800.664.1244 Fax 417.269.4667 E-mail grouphealth@coxhealthplans.com
Mailing Address
Cox HealthPlans
PO Box 5750
Springfield, MO 65801-5750
Or visit us at
Cox HealthPlans
Kelly Plaza
3200 S. National, Building B
Springfield, MO 65807