The documents below explain exactly what your plan covers and what it does not include, how much you have to pay for care, how to access health care, and much more. You can click on the links to view the form online or download it. If you need a hard copy mailed to you, call Customer Service at 1-866-907-1906.
Plan documents
Evidence of Coverage (EOC)
Schedule of Benefits (SB)
The SB details the fees associated with each type of health care service covered by your plan. This includes your deductible and out-of-pocket maximum amounts.
- Gold
- AI/AN Gold Zero Cost Share
- AI/AN Gold Limited Cost Share
- Silver
- Silver 73
- Silver 87
- Silver 94
- AI/AN Silver Zero Cost Share
- AI/AN Silver Limited Cost Share
- Bronze
- AI/AN Bronze Zero Cost Share
- AI/AN Bronze Limited Cost Share
Summary of Benefits and Coverage (SBC)
The SBC gives a snapshot, in plain language, of your health plan’s costs, benefits, covered health care services, and other features.
- Gold
- AI/AN Gold Zero Cost Share
- AI/AN Gold Limited Cost Share
- Silver
- Silver 73
- Silver 87
- Silver 94
- AI/AN Silver Zero Cost Share
- AI/AN Silver Limited Cost Share
- Bronze
- AI/AN Bronze Zero Cost Share
- AI/AN Bronze Limited Cost Share
Electronic Funds Transfer (EFT) Authorization Form
Our secure E-Bill Express payment portal allows you to pay your monthly premiums and medical bills online. If you prefer not to use the online payment system, you can submit payment by Electronic Funds Transfer (EFT). Use the form below to notify us if you prefer this payment option.
Standard Consumer Notice
Know your rights under the Balance Billing Protection Act. Beginning January 1, 2020, Washington state law protects you from ‘surprise billing’ or ‘balance billing’ if you receive emergency care or are treated at an in-network hospital or outpatient surgical facility.
Member Rights Forms
As a Cascade Select member, you have certain rights designed to protect you when you get health care.
- Member Rights and Responsibilities
- Notice of Privacy Practices
- Notice of Disclosure
- Authorization to Disclose Protected Health Information
- Authorization to Release Confidential Substance Use Disorder Treatment Information
- Request for Restriction(s) on the Use and Disclosure of Protected Health Information
- Request for Correction/Amendment of Protected Health Information
- Request for Confidential Communications
- Request for an Accounting of Disclosures
- Privacy/Security Incident Report
- Report Potential Fraud/ID Theft
Appointing a Representative
An appointed representative is a relative, friend, advocate, doctor, or another person who is authorized to act on your behalf in obtaining a grievance, coverage determination, or appeal. If you would like to appoint a representative, both you and your representative must complete the form and mail it to Community Health Network of Washington.
Completed forms can be mailed to:
Community Health Network of Washington Cascade Select
1111 Third Avenue, Suite 400
Seattle, WA 98101
Did you know that certain prescription medicines are available as a 90-day supply? Medicine that you take on a long-term basis to manage your health is called a “maintenance drug.” A 90-day supply makes it easier to keep taking the medicine you need to feel your best. You may also be eligible to receive your long-term medications through free home delivery.
