Health Net

Local affordable health insurance that helps keep people healthy and companies growing. It is our mission to help people be healthy, secure and comfortable.

Provider Finder

Form Name Effective Date Download Form
Large Group Business Application for Group Term Life Insurance Policy
Download
Large Group Business Application
Download
Large Group Electronic Check Form (For New Business Groups)
Download
Large Group Purchaser Claims Data Request Attestation Form
Download
Form Name Effective Date Download Form
Authorization for Disclosure of PHI Form (Spanish)
Download
Authorization for Disclosure of PHI Form
Download
Claim Form - Dental
Download
Claim Form - Life Insurance (Spanish)
Download
Claim Form - Life Insurance
Download
Claim Form - Rx
Download
Claim Form - Vision
Download
Employee Evidence of Insurability Life Form
Download
Employee Group Insurance Conversion Form
Download
Employee Life Insurance Enrollment and Change Form (Spanish)
Download
Employee Life Insurance Enrollment and Change Form
Download
Large Group Employee Enrollment Form (Spanish)
Download
Large Group Employee Enrollment Form
Download
Form Name Effective Date Download Form
Other
Enhanced Choice Supplemental
Summary
Form Name Effective Date Download Form
Small Group Portfolio
Download
Enhanced Choice Supplemental
Download
PureCare Wallet Instructions
Download
Form Name Effective Date Download Form