For your convenience, we've categorized our most frequently used forms.
If you can't find the form you need or require further assistance, please contact us.
Request for ratesCensus template
Group size certification
By the 1st of each month:
By the 20th (for new groups) or the 15th (for renewing groups) of each month:
Follow these steps to complete your enrollment:
Complete the necessary enrollment forms:
For 2020 plans
2020 group master application 2020 group master application benefit selections
For 2019 plans2019 group master application 2019 group master application benefit selections
or circle, sign, and date the rate exhibit to acknowledge your plan choice(s)
Instructions for auto enrollment spreadsheetAuto enrollment spreadsheet (for groups with 10 or more enrolled employees)Member enrollment and change application (for groups with under 10 enrolled employees)
Other coverage questionnaireWaiver of coverage
Return completed enrollment materials to AKPBCSmallGrpSS@premera.com.
By the 1st of each month, Premera must receive:
By the 20th of each month, Premera must receive:
Complete your enrollment application:
Group master application 51+
Circle, sign, and date the rate exhibit to acknowledge your plan choice(s)
Instructions for auto enrollment spreadsheetAuto enrollment spreadsheet (for groups with 10 or more enrolled employees)Other coverage questionnaireWaiver of coverage
Note: Forms and documents will be provided for any groups requesting self-funded or defined funded options. Binder check will be required for Stop Loss.
Completed enrollment materials must be received at Premera well in advance of the 1st of the month for new groups beginning coverage on the 1st of the following month to ensure eligibility and receipt of ID cards by the start date.
Note: Forms and documents will be provided for any groups requesting self-funded or defined funded options. A binder check will be required for stop loss.
Medicare Secondary Payer (MSP) - this form is used for employer groups to report group size and Medicare beneficiary changes to Premera
MSP change form
Medicare prescription drug program formsMedicare prescription drug program creditable coverage noticeMedicare prescription drug program non-creditable coverage notice
This section provides forms for Express Scripts home delivery, prescription drug reimbursement, and other pharmacy-related forms.
Health, allergy, and medication questionnairePharmacy mail-order formPrescription drug reimbursementPrescription drug reimbursement Form (for Alyeska Medical Retirees)Secondary insurance drug claim
Use these forms to enroll or renew your group into a personal funding account, such as an FSA, HRA, or HSA.
Personal funding account enrollment and change applicationPersonal funding account setup form - for small groups up to 50Personal funding account setup form - for large groups
This section includes release of information forms.
Authorization Form Self-Funded Alaska
Authorization Form Fully Insured Alaska
Authorization for release of psychotherapy notes
Disclosure accounting request
Information release form - Give someone permission to obtain and discuss personal and health information, including sensitive information such as substance abuse, reproductive health, and mental health. Members can be authorized to see sensitive information on Premera.com or ConnectYourCare (personal funding account).
Request for amendment of records
Request for inspection of records
Check this section for other frequently used forms.
Affidavit of domestic partnership
Deductible credit form
Electronic funding authorization
Electronic funding authorization for accounts payable
Essential preventive health services for adults (grandfathered plans)
Essential preventive health services for adults (non-grandfathered plans)
Group eligibility adjustment form
Preventive screening services (non-grandfathered plans)
Request for certification of disabled dependent
Self-funded health plan authorized representative disclosure form
Student status verification
Waiver of coverage
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