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
Tax Form 1095 provides proof of health plan coverage. It may be needed to help you file your taxes. You can also find more details about Form 1095 on IRS.gov, or visit our Healthsource blog post on Form 1095.
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 an FSA (Flexible Spending Account) or HRA (Health Reimbursement Arrangement) to get reimbursed for eligible out-of-pocket medical expenses.
HSA Expense Manual Claim Form - Use this if you have an HSA (Health Savings Account) 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
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
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HSA Authorization form UMB Bank
Medical Provider Medical Necessity Certification - Treating physician 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 )
Automatic Funds Transfer Authorization - Authorize Premera to receive monthly fund transfers from your bank to pay for your individual health plan.
Grandfathered Rate Brochure for Individuals and Families
Non-Grandfather 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-Grandfather 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
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.
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.
Discount Card Reimbursement - This form is only to be used for Affordable Care Act (ACA) Health Care Reform mandated prescription reimbursement for members on the Drug Discount Program.
Depo-Provera Reimbursement Claim Form - Use for reimbursement of your Depo-Provera prescription.
Express Scripts Home Delivery Mail-Order Form - Order prescription drugs through the mail from Express Scripts.
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 - Use for secondary reimbursement of your prescription costs balance where Premera is your secondary coverage.
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