Forms
Cox HealthPlans has provided the following forms to assist you in the administration of your 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.
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.
Are you a registered Cox HealthPlan Employer / Plan Administrator?
Register »If you have any questions or concerns, or need additional assistance, please contact the Cox HealthPlans Marketing Department at:
Phone 417.269.4679 or 1.800.664.1244 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