Request Printed Materials Form

Member Handbooks:
Plan#: Dental Medical   Number of handbooks
Plan#: Dental Medical   Number of handbooks
Plan#: Dental Medical   Number of handbooks

Portability (indicate number needed):

Indemnity Portability Brochure (Indemnity, PPO & POS plans)
Managed Care Portability Brochure (Managed Care)

Provider Directories (indicate number needed):
ODS Network Provider Directory
Managed Healthcare Northwest (MHN) Provider Directory

Other (indicate number needed):
Last Member Newsletter
Individual Options Brochure (for employees who will be terminating group coverage or are not eligible for group coverage)
Prescription Drug Reimbursement Forms
Enrollment Applications

Contact Information
Group name:*

Contact Name:*

Address:

City:

State:       Zip:

E-mail address:*

Daytime telephone:

Other questions or comments:

A marketing representative will respond to your inquiry promptly. If ordering information, please allow extra time for mail delivery.