Use these categories for quick access to the forms you need. If you require further assistance, please contact us.
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
Request for rates
Group size certification
Group Enrollment and Renewals
By the 1st of each month:
Completed enrollment/renewal materials for new/renewing groups must be received at Premera by the first of each month for groups requesting personal funding account setup to ensure eligibility by the start date.
By the 20th of each month for enrolling, (or 15th for renewing):
Completed enrollment/renewal materials must be received at Premera for all other products for new/renewing groups with effective dates of the 1st of the following month to ensure eligibility by the start date.
Follow these steps to complete your enrollment:
Request for rates form (51-99)
Census template (51-99)
Groups with 100 or more employees enrolled, please contact your Premera sales representative.
Completed implementation materials must be received at Premera well in advance of the first of the month to ensure eligibility and receipt of ID cards by the groups start date.
Group master application
Circle, sign and date the Rate Exhibit to acknowledge your plan choice(s)
Enrollment spreadsheet (membership adds/drops or plan changes)
Other coverage questionnaire
Note: Forms and documents will be provided for any groups requesting self-funded or defined funded options. Binder check will be required for stop loss.
Completed renewal documents must be received at Premera well in advance of the first of the month for renewing groups beginning coverage on the first of the following month to ensure eligibility and receipt of ID cards, by the groups start date.
Follow these steps to complete your renewal:
Note: Forms and documentation will be provided for any groups requesting self-funded or defined funded options.
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 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
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).
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
Request for certification of disabled dependent