Here you’ll find the most commonly used Premera member forms in Adobe .pdf format (unless otherwise noted). Don’t have Adobe Reader? Get it here
Member appeal and authorization form - Request an appeal of a decision and give your permission for another person to submit an appeal on your behalf.
Complaint and appeal rights - Learn more about Premera’s appeal process.
For plans renewing October 1, 2010 or after, if you have questions regarding the appropriate appeal process for your plan, contact the customer service telephone number shown on the back of you ID card.
Dependent care account claim form
FSA/HRA expense manual claim form - Get reimbursed for eligible out-of-pocket expenses if you have a flexible spending account (FSA) or a health reimbursement arrangement (HRA).
HSA expense manual claim form - Get reimbursed for qualified out-of-pocket medical expenses if you have a health savings account (HSA).
Incident questionnaire - Submit after sustaining an injury or being involved in an accident.
Medical claim form - Submit a medical, dental, or vision claim when the healthcare provider is not submitting it on your behalf.
Other coverage questionnaire - Provide information about other healthcare coverage you may have.
Medical access transportation (air/surface transportation claim form) - Get reimbursement for round trip air or ground transportation to the closest in-network provider for a serious medical condition that can’t be treated locally. Transportation outside of Alaska will be limited to Seattle, WA, when the closest in-network provider is located in Seattle. Pre-approval not required.
Elective procedure travel (medical travel support claim form) - Get reimbursement for certain travel expenses when traveling outside Alaska for approved elective (non-emergency) surgeries. Pre-approval required.
Authorization for release of psychotherapy notes - Allow access to notes made by medical professionals providing psychiatric or psychological services.
Disclosure accounting request - Request a record of how we disclose information about you for reasons other than our normal business functions.
Information release form - Give someone permission to obtain and discuss your personal and health information, including sensitive information such as substance abuse, reproductive health, and mental health. You can also authorize members on your plan to see your sensitive information on Premera.com or ConnectYourCare (personal funding account).
Non-disclosure request - Tell us your requests about sharing your health information.
Request for amendment of records - Change your official personal information record that we maintain.
Request for inspection of records - Request certain records we maintain containing your personal information.
Individual and family plans - 2015 plans and after
HSA authorization form UMB Bank - Open a health savings account (HSA).
Medical provider medical necessity certification - Treating doctor should complete this form for a full-time student dependent who suffers a serious injury or illness and needs to reduce hours or take a leave of absence from school.
Member biometric screening results form - Record and submit your biometric screening results. Please be sure to sign the form before faxing.
Other coverage questionnaire enrollment - Notify us that you have other coverage (such as medical, dental, prescription, vision or Medicare).
Preventive screenings services
Tobacco certification form - For plans as of January 1, 2014 enrollment dates.
Grandfathered and non-grandfathered extended plans
Application for the addition of family members - For grandfathered individual and family plans.
Tobacco certification form
Affidavit of domestic partnership for groups - Verify that your medical plan allows a domestic partner to be eligible for coverage on your plan.
Deductible credit form - Verify deductibles applied toward plan members.
Dental provider nomination form
2017 group member enrollment and change application - Update member information such as adding a dependent.
Group waiver of coverage - Decline coverage if offered.
Request for certification of disabled dependent - Declare that a member is financially responsible for their over-age dependent due to disability.
Student status verification - Verify with us that you are a full-time student.
Medicare Supplement replacement notice - Use this form if you are replacing your current Medicare Supplement or Medicare Advantage coverage.
Medicare Supplement automatic transfer form - Make your monthly payments easier and sign up for automatic funds transfer.
Drug discount program form - Get reimbursement for your prescription costs if you are a member of the Affordable Care Act's Drug Discount Program.
Depo-Provera reimbursement claim form - Get reimbursement for your Depo-Provera prescription.
Express Scripts home delivery order form - Request home delivery of your medications.
Health, allergy & medication questionnaire - Complete this questionnaire for all new mail prescriptions to help protect yourself from potentially harmful side effects and medication interactions.
Secondary insurance prescription drug claim form - Request reimbursement for the balance of your
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