Producer Forms

Application for the addition of family members to an individual/family or group conversion plan

Tobacco certification form

Non-smoker certification form

Underwriting plan change matrix

Claim form

Our small group page has forms and other materials available to producers.

Our large group page has forms and other materials available to producers.

Claim form

HSA, FSA, and HRA forms for new/renewing groups

2019 small group funding account setup form

Electronic funding authorization

Personal funding account enrollment & change application

Waiver of coverage

Deductible credit form

Late enrollment acknowledgement (if applicable)

UMB Bank member forms

UMB HSA beneficiary designation form

UMB HSA authorization form

UMB HSA name change request form

UMB HSA account closure/withdrawal request

UMB HSA funds transfer

HSA expense manual claim form

Bank information

UMB terms and conditions

UMB Bank, member of the FDIC, is one of the largest independent banks in America since 1913. They have been an industry leader in financial healthcare accounts since 1997.

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.

Authorization for release of psychotherapy notes

Disclosure accounting request

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 (medical funding account).

Non-disclosure 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

Producer of record change form

Preventive screening services (non-grandfathered plans)

Student status verification

Waiver of coverage

Request for certification of disabled dependent

Deductible credit form

Electronic funding authorization