Medical Claim Form - Use this form to submit a medical claim when the health care provider is not submitting it on your behalf.
Benefit and Claim Information Authorization Release Form - Use when the release benefit, claim, or personal information is required.
Incident Questionnaire - You may be asked to complete this form after sustaining an injury or being involved in an accident.
Other Coverage Questionnaire - You may be asked to complete this form to provide information about other coverage you may have.
Non-Disclosure Request - Tell us your requests about sharing your health information.
Express Scripts Home Delivery Mail-Order Form - Complete this form to have Express Scripts fill your prescriptions by mail.
Health, Allergy & Medication Questionnaire - Complete this questionnaire for all new mail prescriptions to help protect yourself against potentially harmful drug interactions and side effects.
Prescription Drug Reimbursement Form - Apply for reimbursement of your prescription costs.
Secondary Insurance Prescription Drug Claim Form - Complete this form if you have secondary prescription coverage and want to be reimbursed.
Preventive Care Drug List - This list represents certain common generic medications that are covered in full under the High Deductible PPO Plan and is subject to change without prior notification.
FSA Expense Manual Claim Form - Need to file a Flexible Spending Account claim for Reimbursement? Start here.
FSA Dependent Day Care Account Claim Form - Need to file a Dependent Care Flexible Spending Account claim for Reimbursement? Start here.
HSA Withdrawal Form - Need to file a Health Savings Account claim for Reimbursement? Start here.
Health Savings Account (HSA) Beneficiary Designation Form - Designate a beneficiary or beneficiaries for your Health Savings Account.
Personal Health Account Refund Form - Need to repay your healthcare or Dependent Care account for amounts used for ineligible items? Start here.
Health Saving Account (HSA) Name Change Request Form - Need to update your name on your HSA account with UMB? Complete and submit with supporting documentation.
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