Inclusive Health State Option Forms

For your convenience you may access the most commonly used documents by
following the links below. All of the forms and brochures are in PDF format. If you do not have Adobe Acrobat Reader, download it here.



Application Forms

• 2012 Enrollment Application - print version | online version
  
• IH Member Change Form - print version | online version
  
• HCTC Addendum to the State Option Application
• Enrollment Checklist
  
• Automatic bank draft application
  
• List of qualifying medical conditions for State Option
  

Rate Tables

• Inclusive Health - State Option Rate Table - with HCTC
  
• Inclusive Health - State Option Rate Table - without HCTC included
  

State Policy Plan Information

• PPO 1000 | PPO 2500 | PPO 3500 | HDHP 5000

Additional Materials

• IH State Brochure
  
• ID Card (sample)
  
• Explanation of Benefits