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Broker Information

Broker Forms

Indiana Enrollment Application

Kentucky Enrollment Application

PHI Release Form

Medical Transition of Care Form

Pharmacy Transition of Care Form

Pharmacy Reimbursement Form

Health Claim Reimbursement Form

Underwriting Checklist - Sm. Group

Underwriting Checklist - Lg. Group (51+)

Underwriting Summary Sheet

Universal Medical Questionnaire Form - IN/KY Sm. Group (2-25)

Medical Questionnaire Form - Sm. Group (26-50)

Medical Questionnaire Form - Lg. Group (51+)

WHP Waiver Form

Medicare Brokers:

Medicare AppFax Program