Producer Forms

Everything you need - in one convenient place

Here you'll find a variety of our most frequently used producer forms. If you can't find the form you need or require further assistance, contact your Premera account representative.

Group sales forms

Form

Funding type

Group size

Language

2026 Benefit Selection Worksheet

Fully insured

Small

English

2026 Employer Group Application (1-50)

Fully insured

Small

English

2026 Employer Group Application (51+)

Fully insured

Large

English

Census Spreadsheet (1-50)

Fully insured

Small

English

Census Spreadsheet (51-99)

All funding types

Large

English

Enrollment spreadsheet (for 10+ enrolled employees)

All funding types

All

English

Enrollment Exception Request

All funding types

All

English

Group Change Notification

All funding types

All

English

Group Size Attestation

All funding types

All

English

Medicare Prescription Drug Non-creditable Coverage

All funding types

All

English

Medicare Secondary Payer Change

All funding types

All

English

2026 Member Enrollment and Change Application

All funding types

All

English

2026 Solicitud de inscripción y cambios del miembro (Member Enrollment and Change Application)

All funding types

All

Spanish

Individual and family plans

Form	Funding type	Group size	Language
Affidavit of Domestic Partnership	All funding types	Individual	English
Authorization for Release of Psychotherapy Notes	All funding types	Individual	English
Claim Reimbursement Request	All funding types	Individual	English
Home Delivery Order Form	All funding types	Individual	English
HSA Account Closure	All funding types	Individual	English
HSA Designation of Beneficiary form	All funding types	Individual	English
HSA Trustee to Trustee Transfer form	All funding types	Individual	English
Incident Questionnaire	All funding types	Individual	English
Information Release	All funding types	Individual	English
Medicare Prescription Drug Non-creditable Coverage	All funding types	Individual	English
Non-Disclosure Request	All funding types	Individual	English
Oral Chemotherapy Reimbursement	All funding types	Individual	English
Other Coverage Questionnaire Enrollment	All funding types	Individual	English
Request a Change in Your Records	All funding types	Individual	English
Request a Copy of Your Records	All funding types	Individual	English
Request a Record of Premera Disclosures	All funding types	Individual	English
Secondary Insurance Prescription Drug Claim	All funding types	Individual	English
Student Status Verification	All funding types	Individual	English
Tobacco Use Certification	All funding types	Individual	English
Transition of Care	All funding types	Individual	English

Membership and billing

Form	Funding type	Group size	Language
Claim Reimbursement Request	All funding types	All	English
Deductible and Out of Pocket Credit	All funding types	All	English

Personal funding accounts

Form	Funding type	Group size	Language
Employer PULL ACH Authorization Form	All funding types	All	English
Funding Account Employer Administration Guide (1-50)	All funding types	Small	English
Funding Account Employer Administration Guide (51+)	All funding types	Large	English
Funding account setup for large groups (51+)	All funding types	Large	English
Funding account setup for small groups (1-50)	Fully insured	Small	English
HSA Account Closure	All funding types	All	English
HSA Designation of Beneficiary form	All funding types	All	English
HSA Expense Manual Claim	All funding types	All	English
HSA Trustee to Trustee Transfer form	All funding types	All	English
Personal Funding Accounts Enrollment and Change Application	All funding types	All	English

Miscellaneous

Form	Funding type	Group size	Language
Affidavit of Domestic Partnership	All funding types	All	English
Authorization for Release of Psychotherapy Notes	All funding types	All	English
Authorization for Release of Summary Health Information - Fully insured	Fully insured	All	English
Authorization for Release of Summary Health Information - Self-funded and OptiFlex	Self-funded, OptiFlex	Large	English
Creditable Coverage Disclosure to CMS	All funding types	Small	English
Dental Provider Nomination Form	All funding types	Large	English
Disabled Dependent Certification	All funding types	All	English
Enrollment Center and Ebilling Authorization for Release of Detailed Group and Membership Information	All funding types	All	English
How to Request a Record of Premera Disclosures	All funding types	All	English
Information Release	All funding types	All	English
Non-Disclosure Request	All funding types	All	English
Request a Change in Your Records	All funding types	All	English
Request a Copy of Your Records	All funding types	All	English
Request a Record of Premera Disclosures	All funding types	All	English
Student Status Verification	All funding types	All	English
Tobacco Use Certification	All funding types	All	English
Transition of Care	All funding types	All	English

Pharmacy

Form	Funding type	Group size	Language
Express Scripts Health, Allergy & Medication Questionnaire	All funding types	All	English
Express Scripts Home Delivery Mail-order form	All funding types	All	English
Formulario de Pedido de Envío a Domicilio	All funding types	All	Spanish
Home Delivery Order Form	All funding types	All	English
Oral Chemotherapy Reimbursement	All funding types	All	English
Prescription Drug Reimbursement / Coordination of Benefits Claim Form	All funding types	All	English
Secondary Insurance Prescription Drug Claim	All funding types	All	English

Producer Forms

Everything you need - in one convenient place

Group sales forms

Individual and family plans

Membership and billing

Personal funding accounts

Miscellaneous

Pharmacy