Forms and Documents

ODA Wellness Trust Forms and Documents

Would you like to …

• Request an ODA Wellness Trust quote by completing the Health Plan Participation Request
  
• Complete a FormFire Personal Health Questionnaire request
• Complete a Personal Health Questionnaire (print & complete OR click here for fillable PDF instructions)
• Finalize coverage and enroll:
  • Health Plan Participation Contract
  • Confirmation of Coverage Selection
• Enroll your office in monthly Electronic Funds Transfer (please return the EFT form with a void check)
  
• Add dependents
• Add a newborn
• Remove dependents
  
• Add a new employee - Employee Definitions
• Update the employee census for your office using a Participation Details form
• Waive coverage - Individual Waiver or Waiver Table

Forms should be completed, printed and faxed to the ODA Wellness Trust at 614-340-9444.

An email is generated to confirm receipt of all faxes submitted to ODAWT at (614) 340-9444 within one business day.  Please include with your fax an email address where the fax receipt confirmation should be sent.   If you do not receive a confirmation of fax receipt (please check your junk/spam file), the ODAWT has not received your fax.

Extreme caution should be used when sending personal health information via regular email.