Select Health 2-50

We’re the Mountain region’s highest-ranked health plan.

SelectHealth has ranked highest in member satisfaction among health plans in the Mountain region for five consecutive years. Our partnership with Intermountain Healthcare® and St. Luke’s Health System means that our members have access to some of the best hospitals, clinics, and doctors in the state. And for members who live outside of Idaho or Utah, our NationCare product provides great benefits at a competitive price.

Broker Exchange:

https://selecthealth.org/broker

New Business Submission forms: Medical

Employer Forms-

2015 Group Application

2015 Nationcare Employer Aplication

This will be completed if this is a multistate group. We still need the Group Application completed as well. Please keep in mind they need 70% of the group to be in Utah and/or Idaho.

2015 Echeck Form- Binder Check

This is optional. If they do not complete this we need the first months premium check.

2015 SH Preauthorized Banking Withdrawal Agreement

This is optional. If they do not do the attached ACH form or web pay they will be subject to a $25 monthly admin fee.

Wage and Tax Sample

This is a sample wage and tax.

Employee Forms-

2015 Utah Universal Application

Supplemental Application- Once the employer knows what plan they would like to go with for the company we will give you the supplemental application. Each supplemental application is custom to each employer group so they do not have a generic supplemental application.

2015 Health Equity Enrollment form

Only complete this if they are enrolling on the H.S.A plan and are wanting to utilize Health Equity as their H.S.A bank provider

For quote and rate information for Select Health please contact our staff.

New Business Submission forms and/or Rates: Ancillary

Dental-

2015 Select Health Dental Flyer

2015 Employer Dental Application

2015 Employee Dental Application

Only complete this if they are offering dental not with medical. If they are offering dental along with medical we will not need this application completed. The dental enrollment information will be listed on the employee supplemental application. Each supplemental application is custom to each employer group so they do not have a generic supplemental application.

For quote and rate information for Select Health please contact our staff.

Vision- 5+ groups only

2015 Select Health Vision Flyer

2015 Group Application

The employer vision application is the same as the medical group application

No separate employee application is needed. The vision election section will be listed on the supplemental application.

Life and/or Disability Insurance-

2015 Select Health Life and Disability Flyer

MetLife_Group Application

MetLife Risk Assessment Summary- STD or LTD

Metlife Request for Participation

Enrollment Census

No separate employee application is needed.

Servicing Forms:

Employee changes-

Change of address, change of name, dependent add or removal, and employee terminations.

2015 Change Form

New Hire-

2015 Utah Universal Application

Supplemental Application- Once the company is active with Select Health they will have a specific supplemental form that any new hire’s will need complete. Each supplemental application is custom to each employer group so they do not have a generic supplemental application.

Please note these are forms for 2015.

Provider Search:

Please click the below link for an up-to-date provider search.

https://intermountainhealthcare.org/providers/index.html?brand=sh

Agent of Record form:

Select Health

Do not change any of the wording

Marketing/Sales Material:

SH Network

2015 Sales Packet

The forms posted on this page are for 2015. If you are interested in any forms for previous years or any pre-ACA plan forms please contact our staff.