Browse a wide variety of our most frequently used forms. Can't find the form you need? Contact us.
For additional member forms, view our specific plan pages:
Federal Employee Program (FEP) plans
Note: Carewise audit appeals should go directly to Carewise as noted in the letter sent to providers.
Appeal submission with authorization - Resolve billing issues that directly impact payment or a write-off amount. Note the different fax numbers for clinical vs. general
appeals. Member authorization is embedded in the form for non-contracted providers (section C).
View our individual plans page for
additional appeal forms.
Policy reconsideration - Request reconsideration of a coding policy.
Corrected claim cover sheet - Correct billing info, codes or modifiers, or add an EOP on a previously processed
claim. For more details, see our corrected,
replacement, voided, and secondary claims section.
Support document cover sheet - Submit medical records or other required supporting
documentation to process a claim.
Request to enable real-time claims - Add real-time claims submissions to the estimate tool.
Incident questionnaire - Use when a patient has sustained an injury or was involved in an accident.
Other coverage questionnaire enrollment - Provide information about a patient's other healthcare coverage.
Overpayment notification - Notify Premera of an overpayment your office received.
Letter for refunds less than $25 - We don't send a letter requesting a refund for overpayments of less than $25 per claim. Use this form for
your documentation purposes.
Admission notification and discharge notification
Learn more about submitting
prior authorization, including for DME.
General prior authorization request
Out-of-network exception request - Request in-network benefits for an out-of-network service.
Durable medical equipment (DME)
Pharmacy pre-approval request
Premera uses ProviderSource ™ to manage data for credentialing, recredentialing, and privileging. ProviderSource is free and requires:
View our practitioner credentialing checklist or the Join Our Network page for more information.
Practitioner credentialing/recredentialing addendum - Provide us with your medical record retrieval and practice information.
Behavioral health specialty addendum - Provide us with your behavioral health primary areas of clinical expertise.
Dental provider credentialing application – Request to join our dental provider network.
W-9 - Use this IRS form to provide us with your current taxpayer identification number (TIN).
Practitioner data sheet - Provider specialties that don't require credentialing can use this form to request to join our professional provider network.
Provider update - Email this form to Premera with new information or changes to your current practice or payment structure.
Organization/facility credentialing/recredentialing application - To join our provider network as a facility, complete this application
and a W-9 form. Email us your completed documents. The credentialing process typically takes 60-90 days. Acceptance is based on your application
information and network requirements. If your submitted application is accepted, you'll receive a contract to review and sign. Once you return your signed contract, you’ll receive a counter-signed contract and the effective date of your participation.