For your convenience, we’ve categorized our most frequently used forms below.
If you can’t find the form you need or require further assistance, please contact us.
Ready to request a proposal? Get the necessary forms and supplies here.
Request for Rates Small Group
Census Spreadsheet Template
This section contains support materials including Group Renewal Checklists and Enrollment and Change Applications.
2015 Group Master Application up to 50
Group Master Application 51+
2015 Group Master Application Benefit Selections up to 50
Group Master Application Benefit Selections 51+ HRA
Group Master Application Benefit Selections 51+ Sharefund
Group Verification of Medicare Coverage
Late Enrollment Acknowledgement Form
2015 New Group Enrollment Checklist (up to 50)
Personal Funding Accounts Enrollment and Change Application
2015 Personal Funding Account Setup - For Metallic Groups
Quick Reference Guide for Plan Administrators
2015 Small Group Renewal Checklist
Deductible Credit Form
(For Employer plans only)
Member Enrollment and Change Application
Member Enrollment and Change Application Spanish Version
HIPAA Pre-existing Change Notice and Instructions
HIPAA Pre-existing Change Notice and Instructions Spanish Version
Other Coverage Questionnaire Enrollment
Other Coverage Questionnaire Enrollment Spanish Version
Request for Certification of Disabled Dependent
Waiver of Coverage
Transition of Care Form
HRA Electronic Funding Authorization
UMB HSA Beneficiary Designation Form
UMB HSA Name Change Request Form
UMB HSA Account Closure/Withdrawal Request
UMB HSA Funds Transfer
HSA Expense Manual Claim Form
Form used for employer groups and multiple employer groups to report group size and Medicare beneficiary changes to Premera that may impact MSP rules
MSP Change Form
Get forms for Express Scripts Home delivery, Prior Authorization and Prescription Drug Reimbursement.
Mail-Order Form - Order prescription drugs through the mail from Express Scripts. On behalf of Premera, Express Scripts is an independent company providing pharmacy benefit 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.
Visit this section for Release of Information forms.
Authorization for Release of Healthcare Information and Records
Authorization for Release of Psychotherapy Notes
Disclosure Accounting Request
Request for Amendment of Records
Request for Inspection of Records
This section is for other frequently used forms including Affidavits of Domestic Partnership and more.
Affidavit of Domestic Partnership
Group Eligibility Adjustment Form
Medicare Prescription Drug Program Creditable Coverage Notice
Medicare Prescription Drug Program Creditable Coverage Notice – Employer Template
Medicare Prescription Drug Program Non-Creditable Coverage Notice
Medicare Prescription Drug Program Non-Creditable Coverage Notice – Employer Template
Preventive Screening Services (non-grandfathered plans)