Employer Forms

Ready to request a proposal? Get the necessary forms and supplies here.
Census spreadsheet template

This section contains support materials including group renewal checklists and enrollment and change applications.

Group enrollment

Large group

• 2023 Group Master Application 51+ - Fully insured
• 2023 Group Master Application 51+ for Premera HMO
• Group Master Application - Self-funded
• Group Master Application - Optiflex

Small group

• 2023 Small Group Master Application up to 50
• 2023 Small Group Benefit Selection Worksheet up to 50 - Medical
• 2023 Small Group Benefit Selection Worksheet up to 50 - Dental
• Late Enrollment Acknowledgement form

Additional group forms

• Quick Reference Guide for Plan Administrators

Member enrollment

Small group

• 2023 Member Enrollment & Change Application - English
• Inscripción de Miembros de Grupos Pequeños y Solicitud de Cambios (Small Group Member Enrollment and Change Application)

Large group

• 2023 Member Enrollment & Change Application - English
• Inscripción de Miembros y Solicitud de Cambios - Member enrollment and change application
• 2023 Member Enrollment & Change Application HMO - English
• 2023 Inscripcion de Miembros y Solicitud de Cambios HMO - (Member Enrollment & Change Application HMO)

Additional group forms

• Deductible credit form
• Other coverage questionnaire enrollment - English
• Cuestionario para inscripci ón en otras coberturas - (Other coverage questionnaire enrollment)
• Request for certification of disabled dependent
• Waiver of coverage
• Waiver of Coverage Premera HMO
• Transition of care form

Personal funding accounts

• 2023 Personal funding account setup form - for large groups
• 2023 Personal funding account setup form - for small groups
• Funding Account ACH Authorization
• HSA Account Closure form
• HSA Designation of Beneficiary form
• HSA Trustee to Trustee Transfer form
• Personal funding accounts enrollment and change application
• Funding Account Employer Admin Guide – small groups
• Funding Account Employer Admin Guide - large groups

Group Plans

Form used for employer groups and multiple employer groups to report group size and Medicare beneficiary changes to Premera that may impact MSP rules

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, pre-approval and prescription drug reimbursement.

Mail-order form - Order prescription drugs through the mail from Express Scripts. Express Scripts Home Delivery is an independent company that provides mail-order pharmacy services on behalf of Premera Blue Cross.
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.

Information release forms - 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 a personal funding account.

• Authorization for release of psychotherapy notes
• Disclosure accounting request
• Non-disclosure 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 plans
• Group eligibility adjustment form
• Medicare prescription drug program non-creditable coverage notice
• Preventive screening services (non-grandfathered plans)