Use these categories for quick access to the forms you need. If you require further assistance, please contact us.
Individual and Family Enrollment Application - (For non-grandfathered plans with start dates on or after May 1, 2012)
Application for the Addition of Family Members to an Individual/Family or Group Conversion Plan
Existing Member Dental Application
Tobacco Certification Form - For plans as of 1/1/14 enrollment dates
Non-Smoker Certification Form - For plans prior to 1/1/2014
Underwriting Plan Change Matrix - For plans with start dates on or after May 1, 2012.
This section provides Fax-back forms to submit a request for review and approval and forms related to Express Scripts Home Delivery or prescription drugs
Express Scripts Home Delivery Mail-Order Form - Order prescription drugs through the mail from Express Scripts. On behalf of Premera, Express Scripts is an independent company providing pharmacy benefits services.
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.
This section provides release of information forms
Authorization for Release of Healthcare Information and Records
Authorization for Release of Psychotherapy Notes
Disclosure Accounting Request
Request for Amendment of Record
Request for Inspection of Records
Affidavit of Domestic Partnership
Individual Domestic Partner Eligibility Requirements
AFT Authorization Form for Individual Major Medical
HSA Authorization Form for UMB Bank
Producer of Record Change Form
Student Status Verification
Waiver of Coverage
Our small group page has forms and other materials available to producers.
Our large group page has forms and other materials available to producers.
By the 1st of each month:
Use these forms to enroll/renew or renew your group onto a personal funding account, such as an FSA, HRA, or HSA.
Personal Funding Account Enrollment and Change Application
Personal Funding Account Setup Form - For Metallic Groups up to 50
Preventive Screening Services (non-grandfathered plans)
Request for Certification of Disabled Dependent
Deductible Credit Form
Electronic Funding Authorization
To order individual products and supplies:
Fill out the:
Producer Supply Form
Save a copy for your records.
Email it to Producer Supply. Or fax the completed form to 907-258-1619.