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

Proposals

Request for rates

Census template

Pre-Renewal

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:

1. Complete the following necessary enrollment forms:
   For 2019 plans
   
   • 2019 group master application
   • 2019 group master application benefit selections
   Or circle, sign and date the rate exhibit to acknowledge your plan choice(s)
   • Enrollment spreadsheet (for groups with 10 or more enrolled employees)
   • Member enrollment and change application (for groups with under 10 enrolled employees)
   • Other coverage questionnaire
   • Waiver of coverage
2. Send completed enrollment materials to AKPBCSmallGrpSS@PREMERA.com.

Proposals

Request for rates form (51-99)

Census template (51-99)

Groups with 100 or more employees enrolled, please contact your Premera sales representative.

Pre-renewal

Group size certification

Group enrollments

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.

Follow these steps to complete your enrollment:

1. Required documents:

   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

2. Return completed enrollment documents for groups with 51-99 employees to AK51-99@premera.com. Groups with 100 or more employees, please send to your Premera sales representative.

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.

Group renewals

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:

Circle, sign and date the Rate Exhibit to acknowledge your plan choice(s)

Required documents:

1. Group verification report (provided by Premera)
2. Enrollment spreadsheet (membership adds/drops or plan changes)
3. Other coverage questionnaire
4. Return completed enrollment documents for groups  with 51-99 employees to AK51-99@premera.com. Groups with 100 or more employees, please send to your Premera Account Manager.

Note: Forms and documentation will be provided for any groups requesting self-funded or defined funded options.

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