Account Installation Forms

AmeriHealth Forms Online — New Jersey

In the Account Installation section you will find “everyday” forms you need to process an account installation transaction via ROAM.

AmeriHealth New Jersey SEH Account Installation Checklist:

Required for all SEH groups

• AmeriHealth New Jersey SEH Group Application
• NJ Small Employer Certification
• Signed copy of ROAM quote including proposal and reconciliation summary
• Waivers, completely filled out
• First month’s premium check

AmeriHealth New Jersey Smiles for Health Plan (one of the following)

• United Concordia Dental Group Application
• United Concordia Dental Attestation Form

Additional documents required for groups (2-4 employees)

• IRS form WR-30

If WR-30 is not available please submit: Proof of Business (one of the following)

• IRS 1040 schedule C (sole proprietorship or farm)
• IRS 1065 (partnership)
• IRS 1120 (C corp or S corp)
• IRS 941 (church or non profit)
• IRS 990 (tax exempt org.)
• CPA letter on letterhead
• Articles of Incorporation, Certification of Formation, Certification of Incorporation (signed and stamped or receipt with issuing date)
• Business License
• Partnership agreement (stamped by state or notarized)

Payroll Documents (one of the following per each employee)

• W-2
• W-4 (for new hires only)
• Schedule C, Schedule K-1, or Schedule F (for owners only)
• CPA letter

Important: if you transfer the images to a photocopy, please make certain the bar codes on all pages appear in the bottom right of each page when face up.

Forms are in PDF format.