Resource Center

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2019 Resources

2019 Large Group Application
2019 Small Group Application
2019 Employee Enrollment Form | Spanish
2019 Hybrid Group Application
2019 Hybrid Employee Application | Spanish
Hybrid ASO

All HMO Group Applications must also complete the following Disclosure Form.

2019 Large Group HMO Plans

2019 Select 001 HMO
2019 Select 002 HMO
2019 Select 003 HMO
2019 Select 500-80 HMO
2019 Select 1000-80 HMO
2019 Select 1000-100 HMO
2019 Select 1500-80 HMO
2019 Select 2000-80 HMO
2019 Select 2000-100 HMO
2019 Select 2500-80 HMO
2019 Select 3000-80 HMO
2019 Select 3000-100 HSA HMO
2019 Select 5000-80 HMO
2019 Select 5000-100 HSA HMO
2019 Select 6550-100 HSA HMO
2019 Select 6600-100 Standard HMO

2019 Large Group PPO Plans

2019 Select 002 PPO
2019 Select 1000-80 PPO
2019 Select 1000-100 PPO
2019 Select 1500-80 PPO
2019 Select 2000-80 PPO
2019 Select 3000-80 PPO
2019 Select 3000-100 PPO
2019 Select 5000-80 PPO
2019 Select 5000-80 HSA PPO
2019 Select 6550-100 HSA PPO
2019 Select 6600-100 Standard PPO

2019 Large Group COC and EOC

2019 Certificate of Coverage - Large Group
2019 Evidence of Coverage - Large Group

2019 Small Group HMO Plans

2019 Select Gold 001 HMO
2019 Select Gold 1000 HMO
2019 Select Gold 1500 HMO
2019 Select Gold 2000 HMO
2019 Select Platinum 500 HMO

2019 Small Group PPO Plans

2019 Select Gold 2000 PPO

2019 Small Group HMO Hybrid Plans

2019 Select 001 HMO
2019 Select 002 HMO
2019 Select 500 HMO
2019 Select 1000 HMO
2019 Select 1500 HMO
2019 Select 2000 HMO
2019 Select 3000 HMO
2019 Select 3000 HSA HMO
2019 Select 6850 HMO
2019 Select 7500 HMO

2019 Small Group PPO Hybrid Plans

2019 Select 2000 PPO
2019 Select 3000 PPO

2019 Small Group COC and EOC

2019 Certificate of Coverage - Small Group
2019 Evidence of Coverage - Small Group

Additional Submission Forms

Late Submission Form
Deductible Credit Form
Employee Termination Form
Employee Verification Form
Group Data Submission Agreement
CCHP 2019 Form
ACH Form

2018 Applications

2018 Large Group Application
2018 Small Group Application
2018 Employee Enrollment Form | Spanish

All HMO Group Applications must also complete the following Disclosure Form.

2018 Large Group HMO Plans

2018 Select 001 HMO
2018 Select 002 HMO
2018 Select 500-80 HMO
2018 Select 1000-80 HMO
2018 Select 1500-80 HMO
2018 Select 2000-80 HMO
2018 Select 2000-100 HMO
2018 Select 2500-80 HMO
2018 Select 3000-80 HMO
2018 Select 3000-100 HSA HMO
2018 Select 4000-80 HMO
2018 Select 5000-80 HMO
2018 Select 5000-100 HSA HMO
2018 Select 6550-100 HSA HMO
2018 Select 6600-100 HMO

2018 Large Group PPO Plans

2018 Select 1000-80 PPO
2018 Select 1500-80 PPO
2018 Select 2000-80 PPO
2018 Select 2500-80 PPO
2018 Select 3000-80 HSA_PPO
2018 Select 3000-80 PPO
2018 Select 5000-80 HSA_PPO
2018 Select 5000-80 PPO
2018 Select 6550-100 HSA PPO
2018 Select 6600-100 PPO

2018 Large Group COC and EOC

2018 Certificate of Coverage - Large Group
2018 Evidence of Coverage - Large Group

2018 Small Group HMO Plans

2018 Select Bronze 6850 HMO
2018 Select Silver 002 HMO
2018 Select Silver 3000 HMO
2018 Select Silver 3000 HSA HMO
2018 Select Gold 001 HMO
2018 Select Gold 1000 HMO
2018 Select Gold 1500 HMO
2018 Select Gold 2000 HMO
2018 Select Platinum 500 HMO

2018 Small Group PPO Plans

2018 Select Gold 2000 PPO

2018 Small Group COC and EOC

2018 Certificate of Coverage - Small Group
2018 Evidence of Coverage - Small Group

Successful Returns©

Successful Returns Fact Sheet
Outcomes
Directions to the Facility

WorkLink©

WorkLink Fact Sheet
Quick Reference Guide
Providers Process Guide
Work Status Form
Pre-Authorization Form

Nonsubscribers

Texas Department of Insurance; Division of Workers' Compensation

Longshore

Department of Labor (DOL)
DOL Longshore First Report of Injury
DOL Division of Longshore & Harbor Workers' Compensation (DLHWC)
Longshore FAQ