SMALL GROUP EMPLOYER APPLICATION - healthalliance 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Group Name as shown on your Tax and Wage Statement, followed by the Employer Federal Tax ID Number (TIN). Fill in the Group Contact, Industry Type, Email Address, and both Physical and Billing Addresses.
3. In SECTION 1: ADDITIONAL GROUP INFORMATION, provide details such as the total number of employees and the requested effective date for Health Alliance Northwest. Indicate if Health Alliance is your sole source of health insurance and list any other carriers if applicable.
4. Complete SECTION 2: MEDICARE SERVICES by indicating interest in a Medicare Advantage plan and providing necessary contact information. Ensure you specify the effective date for Medicare plans.
5. In SECTION 3: THIRD PARTY ADMINISTRATIVE SERVICES, answer whether you have a Health Savings Account (HSA) or an HRA.
6. If applicable, fill out SECTION 4: BROKER INFORMATION with your broker's details and signature. Finally, review SECTION 5: GROUP INFORMATION to attest to the accuracy of all provided information before signing.

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