Health Benefit Representative Contact/Access Request Form

HBR Contact Information

The State Health Plan (Plan) communicates with HBRs on a regular basis and it is critical, that the Plan have accurate information for each employing unit.

It is the responsibility of each employing unit to ensure the Plan has correct contact information.

By including your email address, you agree to be included on the Plan's email list to receive HBR Updates/Alerts.

Thank you in advance!

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* 1. HBR First and Last Name

First Name

Last Name

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* 2. Title

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* 3. Employing Unit

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* 4. Group Type

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* 5. Employing Unit Address

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* 6. HBR Email Address

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* 7. HBR Phone

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* 8. HBR Access Needed (check all that apply)

Eligibility and Enrollment

Premium Billing

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* 9. Check the boxes below in which you serve as the contact.

Premium Billing

Exceptions

DEVA (Dependent Audit)

Recovery and Wage Garnishment

Escalation Contact (i.e. HR Director)

If any of the above responsibility belongs to someone else, please list those individuals here.

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* 10. Are you replacing anyone?

Yes

If yes, who are you replacing?

100% of survey complete.