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
Authorization for Appeals - Use this form to provide your approval for another party to submit an appeal on your behalf.
Member Appeal Request - Use this form to request an appeal of a decision.
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 I.D. card.
Dependent Care Account Claim Form
FSA/HRA Expense Manual Claim Form - Use this if you have a flexible spending account (FSA) or health reimbursement arrangement (HRA) to get reimbursed for eligible out-of-pocket medical expenses.
HSA Expense Manual Claim Form - Use this if you have an health savings account (HSA) to get reimbursed for qualified out-of-pocket medical expenses.
Incident Questionnaire - Use 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.
Medical Claim Form (SERVICES OUTSIDE USA) - Submit a medical 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.
Transportation Claim Form
Medical Travel Support Claim Form
Authorization for Release of Psychotherapy Notes - Allow access to notes made by medical professionals providing psychiatric or psychological services.
Benefit and Claim Information Authorization Release - Use when release of benefit, claim, or personal information is required.
Disclosure Accounting Request - Request a record of how we disclose information about you for reasons other than our normal business functions.
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
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 - Use this form to record and submit your biometric screening results. Please be sure to sign the form before faxing.
Other Coverage Questionnaire Enrollment - Use to 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 Individual and Family Plan (grandfathered )
2015 Grandfathered Rate Brochure for Individuals and Families
2016 Grandfathered Rate Brochure for Individuals and Families
Non-Grandfathered Rate Brochure Start Date 4/1/10 to 4/15/10 - For plans with original start dates from April 1, 2010 to April 15, 2010
Non-Grandfathered Rate Brochure Start Date 5/1/10 to 12/15/10 - For plans with original start dates from May 1, 2010 to December 15, 2010
2016 Non-Grandfathered Plan Rates - For plans with start dates from May 1, 2016
Tobacco Certification Form
Affidavit of Domestic Partnership - for Groups - Use this form if your medical plan allows a domestic partner to be eligible for coverage on your plan.
Deductible Credit Form - Verify deductibles applied toward plan members.
2017 Group Member Enrollment and Change Application - Update member information such as adding a dependent.
2016 Group Member Enrollment and Change Application - Update member information such as adding a dependent.
Group Waiver of Coverage - Use this form to decline coverage if offered.
Request for Certification of Disabled Dependent - Use to declare that a member is financially responsible for their over-age dependent due to disability.
Student Status Verification - Use to 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 - If you are a member of the Affordable Care Act's Drug Discount Program, use this form for reimbursement of your prescription costs.
Depo-Provera Reimbursement Claim form - Use for reimbursement of your Depo-Provera prescription.
Express Scripts Home Delivery Order form - Save time! 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.
Prescription drug reimbursement form - Download the Premera mobile app and you'll have proof of coverage at your fingertips.
Secondary insurance prescription drug claim form - Are you covered by more than one health plan, with Premera as your secondary coverage? If so, you can request reimbursement for the balance of your prescription costs.
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