MSA Washington: Medical Savings Accounts in Washington

Asuris Northwest Health - Online Application

Application Process and Forms

To apply for any of the Asuris Northwest Health individual medical plans, please complete the following steps:

Fill out the Application (one per family)
Click here to download the Asuris Northwest Health Individual/Family Enrollment Application. Print the application and fill it out completely.
Fill out the Questionnaire (one for each person to be covered)
Click here to download the Standard Health Questionnaire for Washington State. Print and complete the questionnaire for each person to be covered on the plan. Please refer to Completing the Health Questionnaire to determine if this applies.
Provide Proof of Washington State Residency
To be eligible to purchase this plan you must be a Washington state resident.
A photocopy of one of the following must accompany your application to prove residency:
- Valid Washington State Driver's License or Identification Card
- Washington State Voter Registration Card
- Current Utility Bill in your name, including address

Provide Certificate of Creditable Coverage (if available)
Please refer to Credit for Prior Coverage & HIPAA Eligibility for more information. Please note, if you do not have your Certificate of Creditable Coverage at the time of application, please submit your application anyway. Credit for pre-existing condition waiting periods will be credited upon receipt of your Certificate of Creditable Coverage by Asuris Northwest Health.
Do not Send a Payment
Please do not send a rate payment with your application. You will receive a statement from Asuris Northwest Health upon acceptance of your application. If you want to have an automatic draft for monthly premiums download Click here.
Send all Enrollment Materials to:
CDA Insurance Services
P.O. Box 26540
Eugene, OR 97402

Please note: Asuris Northwest Health requires all COMPLETED enrollment materials to be postmarked to their office on or before the 20th of the month. Incomplete enrollments may cause delays in the effective date of your coverage. Please refer to the checklist on the application to avoid delays.

For Example: If you wanted your medical insurance coverage to begin on April 1, you would need to send all of the required, completed enrollment material to Asuris Northwest Health postmarked on or before March 20.

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