FORMS (1VAC55-20).
Adoption Agreement, T20082 (R1/02)
Commonwealth of Virginia Health Benefits Program Application, T20445 (rev. 1/13)
Enrollment Form - The Local Choice Health Benefits Program, T20911 (1/14)
General Notice of Extended Coverage Rights (rev. 3/05)
Interagency Transfer Invoice, Department of Accounts DA-02039 (rev. 7/86)
Commonwealth of Virginia Certificate of Group Health Plan Coverage and Statement of HIPAA Portability Rights (rev. 4/05)
State Health Benefits Program Appeal Form (rev. 5/11)
Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.
As a service to the public, the Virginia Administrative Code is provided online by the Virginia General Assembly. We are unable to answer legal questions or respond to requests for legal advice, including application of law to specific fact. To understand and protect your legal rights, you should consult an attorney.