Life and Health Forms
| Form Number: APP-ASSIGN | | Title: Individual Eligibility Application for the State of Georgia Assignment System | Published: 2007 | | Description: This application must be completed for individuals who are applying for coverage under the State of Georgia individual assignment system. In order to be eligible for coverage under this program, the Administrator must receive this application no later than 63 days following your termination of coverage under your group plan’s continuation of benefits. You may use the enclosed self-addressed envelope or send the application to the address above. Submission of this application does not guarantee coverage. The Administrator and/or insurance company reserves the right to review your responses to determine eligibility for coverage under this plan for you and your dependents. |
| Form Number: GHBAS-1 | | Title: Assignment System Managed Care Policy Form Template (GHBAS-1) | Published: 1998 | | Description: Pre Certification Requirement for Assignment System Managed Care Policy. |
| Form Number: GHBAS-S | | Title: Assignment System Managed Care Schedule of Benefits (GHBAS-S) | Published: 1998 | | Description: Georgia Department of Insurance Managed Care Schedule of Benefits Summary. |
| Form Number: GHIAS-1 | | Title: Assignment System Indemnity Policy Form Template Plan A (GHIAS-1) | Published: 1998 | | Description: Indemnity Pre Certification requirements. |
| Form Number: GHIAS-2 | | Title: Assignment System Indemnity Policy Form Template Plan B (GHIAS-2) | Published: 1998 | | Description: Assignment System Indemnity Policy Form Template Plan B (GHIAS-2) |
| Form Number: GHIAS-S | | Title: Assignment System Indemnity Schedule of Benefits (GHIAS-S) | Published: 1998 | | Description: Assignment System Indemnity Schedule of Benefits |
| Form Number: GID-PPA1 | | Title: Patient Protection Act Application for Certification | Published: 1997 | | Description: Patient Protection Act Application for Certification This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. |
|
|