INCLUSIVE HEALTH - State Option


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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 Kit

2012 Enrollment Application - print version | online version
IH Member Change Form - print version | online version
Enrollment Checklist
HCTC Addendum for Enrollment Application
Automatic bank draft application
List of qualifying medical conditions
Inclusive Health - State Option Rates
Inclusive Health - State Option HCTC Rates
Release of Information - Authorized Representative Form
IH Assist Premium Subsidy Program Application

IH Policy Plan Information

File a Claim

Claim form

Pharmacy Claim Forms

Marketing Materials

Health Care Savings Account Information

Other

W-9 Form

North Carolina Health Insurance Risk Pool, Inc.
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