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Forms

Here you’ll find the most commonly used Premera member forms in Word .doc and Adobe .pdf format. Don’t have Adobe Reader? Get it here.

You can submit forms by signing in to your Premera account and then using the Secure Inbox.

Member appeal and authorization form - employer/group  (PDF document)
Formulario de apelación del miembro  (PDF document)
Note: Use this version if you have a Premera plan through your employer or another group.
Request an appeal of a decision and/or give your permission for another person to submit an appeal on your behalf.

Member appeal and authorization form - individual/family  (PDF document)
Formulario de apelación del miembro  (PDF document)
Note: Use these versions if you have an individual or family plan that you bought independently.
Request an appeal of a decision or give your permission for another person to submit an appeal on your behalf.

Member complaint form - employer/group  (PDF document)
Note: Use this version if you have a Premera plan through your employer or another group.
Senda complaint if you’re unhappy and want to share your feedback with Premera.

Member complaint form - individual/family  (PDF document)
Note: Use this version if you have an individual or family plan that you bought independently.
Senda complaint if you’re unhappy and want to share your feedback with Premera.

Independent Review Organization (IRO)  (PDF document)
These are external medical and contract experts not associated with Premera. We’ll forward your request at no additionalcost to you.
Note: Look at the What’s Next section of your appeal decision letter, you may need to submit your request directly to Alaska Department of Insurance.

Complaint and appeal rights  (PDF document)
Learn more about our appeal process.

Complaint and appeal rights - individual plans  (PDF document)

Medical claim form - Submit a claim for reimbursement when a healthcare provider is not submitting on your behalf.

    Dependent care manual claim form  (PDF document) - File a manual claim for a dependent.

    FSA/HRA expense manual claim form  (PDF document) - 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  (PDF document) - Get reimbursed for qualified out-of-pocket medical expenses if you have a health savings account (HSA).

    Incident questionnaire  (PDF document) - Submit after sustaining an injury or being involved in an accident.

    COVID-19 OTC home test reimbursement claim form - Request reimbursement for COVID-19 tests you have paid for out of your own pocket.

    • Employer-based and group-based plans, use this group form  (PDF document)
      NOTE: Coverage for COVID home test kits ended on May 11, 2023 for most groups. Check your benefits on the member portal to determine if you still have coverage and the process for submitting a claim. If you submit a claim and are not eligible, your claim will be denied.

    Other coverage questionnaire  (PDF document) - 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. Preapproval required.

    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).

    Information release form - employer/group  (PDF document)
    Note: Use this version if you have a Premera plan through your employer or another group.

    Information release form - individual/family  (PDF document)
    Note: Use this version if you have an individual or family plan that you bought independently.

    Non-Disclosure Request
    Request that we not share your personal health information with a specific person or entity.

    Non-disclosure request - employer/group  (PDF document)
    Note: Use this version if you have a Premera plan through your employer or another group.

    Non-disclosure request - individual/family  (PDF document)
    Note: Use this version if you have an individual or family plan that you bought independently.

    Authorization for Release of Psychotherapy Notes
    Allow access to notes made by medical professionals providing psychiatric or psychological services.

    Authorization for release of psychotherapy notes - employer/group  (PDF document)
    Note: Use this version if you have a Premera plan through your employer or another group.

    Authorization for release of psychotherapy notes - individual/family  (PDF document)
    Note: Use this version if you have an individual or family plan that you bought independently.

    Disclosure accounting request
    Request a record of how we disclose information about you for reasons other than our normal business functions.

    Disclosure accounting request - employer/group  (PDF document)
    Request a record of how we disclose information about you for reasons other than our normal business functions.

    Disclosure accounting request - individual/family  (PDF document)
    Note: Use this version if you have an individual or family plan that you bought independently.

    Request for Amendment of Records
    Change your official personal information record that we maintain.

    Request for amendment of records - employer/group  (PDF document)
    Note: Use this version if you have a Premera plan through your employer or another group.

    Request for amendment of records - individual/family  (PDF document)
    Note: Use this version if you have an individual or family plan that you bought independently.

    Request for Inspection of Records
    Request certain records we maintain containing your personal information.

    Request for inspection of records - employer/group  (PDF document)
    Note: Use this version if you have a Premera plan through your employer or another group.

    Request for inspection of records - individual/family  (PDF document)
    Note: Use this version if you have an individual or family plan that you bought independently.

    Individual and family plans

    HSA account application  (PDF document)
    Open a health savings account (HSA).

    Preventive screenings services  (PDF document)

    Group plans

    Affidavit of domestic partnership for groups  (PDF document)
    Verify that your medical plan allows a domestic partner to be eligible for coverage on your plan.

    Deductible credit form  (PDF document)
    Verify deductibles applied toward plan members.

    Dental provider nomination form  (PDF document)

    Member enrollment and change application  (PDF document)
    Update member information such as adding a dependent.

    Group waiver of coverage  (PDF document)
    Decline coverage if offered.

    Request for certification of disabled dependent  (PDF document)
    Declare that a member is financially responsible for their over-age dependent due to disability.

    Medicare Supplement replacement notice  (PDF document)
    Use this form if you are replacing your current Medicare Supplement or Medicare Advantage coverage.

    Medicare Supplement automatic transfer form  (PDF document)
    Make your monthly payments easier and sign up for automatic funds transfer.

    Member appeal and authorization form  (PDF document)
    Request an appeal of a decision and/or give your permission for another person to submit an appeal on your behalf.

    Member complaint form  (PDF document)
    Send a complaint if you’re unhappy and want to share your feedback with Premera.

    Complaint and appeal rights  (PDF document)
    Learn more about our appeal process.

    Depo-Provera reimbursement claim form  (PDF document)
    Get reimbursement for your Depo-Provera prescription.

    Express Scripts home delivery order form  (PDF document)
    Request home delivery of your medications.

    Health, allergy & medication questionnaire  (PDF document)
    Complete this questionnaire for all new mail prescriptions to help protect yourself from potentially harmful side effects and medication interactions.

    Prescription drug reimbursement form  (PDF document)
    Request reimbursement if you paid full price for a prescription at an out-of-network pharmacy.

    Secondary insurance prescription drug claim form  (PDF document)
    Request reimbursement for the balance of your prescription costs if Premera is your secondary insurance.

    Tax IRS form 1095-B

    1095-B is a form you may need when you file taxes, depending on your state law.

    Most members who have health plans through employers will not receive a paper copy of form 1095-B due to a tax law change. However, this form will continue to be available on our member website or by requesting a paper form.

    How to get your tax form 1095-B:

    • Sign in to your Premera account and go to My account and select Tax Form 1095 to find and/or download and print the form. Or go to Secure Inbox to email your request to have the tax form mailed.
    • Call the customer service phone number on the back of your ID card to request the tax form be mailed
    • To mail your request, fill out the 1095-B Mailing Request Form  (PDF document) and follow this document’s instructions for how to get a copy of the tax form

    Planes para individuos y familias (Individual and family plans)

    Formulario de divulgación de información - individuos/familias  (PDF document) (Information Release Form)

    Planes grupales para empleadores (Employer and group plans)

    Formulario de divulgación de información - empleadores/grupales  (PDF document) (Information Release Form)

    Farmacia (Pharmacy)

    Formulario de Pedido de Envío a Domicilio  (PDF document)