This electronic form is intended to be used to ADD, CHANGE or REMOVE employer-sponsored or private health insurance.
This form is also used to apply for Health Insurance Premium Payment (HIPP).
Note: Insurance that will be starting or ending in the future should not be reported on this form until after the change happens.
Documents that may be helpful to complete this form
- Insurance cards for all policies reported
- Digital copy of last two pay stubs or last billing statement if applying for Health Insurance Premium Payment (HIPP) program
- Oregon Medical Care Identification – card issued to individuals receiving Oregon Medical Program health benefits