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Apply for coverage from
Asuris Northwest Health
Asuris Home |
Download Asuris
Enrollment Form and:
• Standard Health Questionnaire for use with coverage that begins on or after June 10, 2010 .
OR - Use the online e-Enrollment
Application
Application Process and Forms
To apply for any of the Asuris Northwest Health individual
medical plans, please complete the following steps:
- Fill out the Application (one per
family)
Download the Asuris Northwest
Health Individual/Family Enrollment Application from the link above. Print
the application and fill it out completely.
- Fill out the Questionnaire (one
for each person to be covered)
Download the Standard Health
Questionnaire for Washington State. Print and complete
the questionnaire for each person
to be covered on the plan. Please refer to Completing
the Health Questionnaire to determine
if this applies.
- Provide Proof of Washington State Residency
To be eligible to purchase this plan you must be a
Washington state resident.
A photocopy of one of the following must accompany
your application to prove residency:
- Valid Washington State Driver's License or Identification
Card
- Washington State Voter Registration Card
- Current Utility Bill in your name, including
address
- Provide Certificate of Creditable Coverage
(if available)
Please refer to Credit
for Prior Coverage & HIPAA Eligibility
for more information. Please note, if you do not have
your Certificate of Creditable Coverage at the time
of application, please submit your application anyway.
Credit for pre-existing condition waiting periods
will be credited upon receipt of your Certificate
of Creditable Coverage by Asuris Northwest Health.
- Do not Send a Payment
Please do not send a rate payment with your application.
You will receive a statement from Asuris Northwest
Health upon acceptance of your application. If you
want to have an automatic draft for monthly premiums
download Click
here.
- Send all Enrollment Materials to:
CDA Insurance LLC
P.O. Box 26540
Eugene, OR 97402
Please note: Asuris Northwest Health
requires all COMPLETED enrollment materials
to be postmarked to their office on or before the 20th
of the month. Incomplete enrollments may cause delays
in the effective date of your coverage. Please refer to
the checklist on the application to avoid delays.
For Example: If you wanted your medical
insurance coverage to begin on April 1, you would need
to send all of the required, completed enrollment material
to Asuris Northwest Health postmarked on or before March
20.
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