Forms

  • Medical Claim form - Use this form to submit a medical claim when the health care provider is not submitting it on your behalf.

    In-network Only Specialist Referral form - If you're on the In-network-Only Plan, ask your Primary Care Provider (PCP) to submit this form for you online. Or, you can print and take this form to your PCP when you need services from a specialist.

    International Claim form - Use this form when you need to submit a claim for services you incurred outside the United States.

    Other Coverage Questionnaire - Provide information about other healthcare coverage you may have.

    Incident Questionnaire - You may be asked to complete this form after sustaining an injury or being involved in an accident.

    Continuity of Care - Are you new to Premera or has your provider, hospital, or facility recently left the Premera network? Find out if you qualify to continue receiving care from your current provider.

    Benefit and Claim Information Authorization Release - Use when release of benefit, claim, or personal information is required.

    Non-disclosure Request - Tell us your requests about sharing your health information.