Employer Forms

Everything you need - in one convenient place.

Below you'll find a variety of our most frequently used employer forms. If you can't find the form you need or require further assistance, please contact us.

Group sales forms

Form	Funding type	Group size	Language
2025 Group Master Application 51+ for fully insured	Fully insured	Large	English
2025 Small Group Benefit Selection Worksheet - Medical	Fully insured	Small	English
2025 Small Group Master Application	Fully insured	Small	English
2025 Group Renewal Checklist	Fully insured	Small	English
2025 New Group Enrollment Checklist	Fully insured	Small	English
OptiFlex Group Master Application	OptiFlex	Large	English
Self-funded Group Master Application	Self-funded	Large	English
Authorization for Release of Detailed Group and Membership Information	All funding types	Small, Large	English
Census Spreadsheet	All funding types	Large	English
Cuestionario para inscripci ón en otras coberturas - (Other coverage questionnaire enrollment)	All funding types	Individual, Small, Large	Spanish
Enrollment Exception Request	All funding types	Small, Large	English
General Agency of Record Change	Fully insured	Small	English
Group Eligibility Adjustment	All funding types	Small, Large	English
Group Size Attestation	All funding types	Small, Large	English
Inscripcion de Miembros de Grupos y Solicitud de Cambios (Member Enrollment and Change Application)	All funding types	Large	Spanish
Inscripcion de Miembros de Grupos y Solicitud de Cambios (Member Enrollment and Change Application)	Fully insured	Small	Spanish
Medicare Prescription Drug Non-creditable Coverage	All funding types	Individual, Small, Large	English
Medicare Secondary Payer Change	All funding types	Small, Large	English
Member Enrollment and Change Application - Large group	All funding types	Large	English
Other Coverage Questionnaire Enrollment	All funding types	Individual, Small, Large	English
Plan Administrator Guide	All funding types	Small, Large	English
2025 Small Group Benefit Selection Worksheet - Dental	Fully insured	Small	English
Small Group Member Enrollment and Change Application	Fully insured	Small	English
Solicitud de inscripción y cambios del miembro	Fully insured	Small	Spanish
Standard Auto Enrollment Spreadsheet Template	All funding types	Small, Large	English
Waiver of coverage	All funding types	Small, Large	English

Premera Blue Cross HMO forms

Form	Funding type	Group size	Language
2025 Small Group Benefit Selection Worksheet up to 50 - Medical for Premera Blue Cross HMO	Fully insured	Small	English
2025 Small Group Master Application up to 50 for Premera Blue Cross HMO	Fully insured	Small	English
2025 Group Master Application 51+ Premera Blue Cross HMO	Fully insured	Large	English
Affidavit of Domestic Partnership Premera HMO	Fully insured	Small, Large	English
Declaración jurada de parejas de hecho	Fully insured	Small, Large	Spanish
Authorization for Release of Summary Health Information - Premera Blue Cross HMO	Fully insured	Small, Large	English
Deductible and Out of Pocket Credit Form	Fully insured	Small, Large	English
Enrollment Center and Ebilling Authorization for Release of Detailed Group and Membership Information	Fully insured	Small, Large	English
Enrollment Exception Request SG HMO	Fully insured	Small, Large	English
Formulario de reclamación presentado por el miembro	Fully insured	Small, Large	Spanish
Incident Questionnaire Member Version Premera HMO	Fully insured	Small, Large	English
Incident Questionnaire Member Version Premera HMO Spanish	Fully insured	Small, Large	English
Late Enrollment Acknowledgement - HMO	Fully insured	Small	English
Member Enrollment & Change Application for Premera Blue Cross HMO	Fully insured	Small	English
Member Enrollment and Change Application - HMO	Fully insured	Large	English
Member Enrollment and Change Application - HMO Spanish	Fully insured	Large	Spanish
Member Submitted Claim Form Premera HMO	Fully insured	Small, Large	English
Member Submitted Claim Form Premera HMO Spanish	Fully insured	Small, Large	Spanish
Other Coverage Questionnaire Enrollment Premera HMO	Fully insured	Small, Large	English
Other Coverage Questionnaire Enrollment Premera HMO Spanish	Fully insured	Small, Large	Spanish
Other Coverage Questionnaire Premera HMO	Fully insured	Small, Large	English
Premera Blue Cross HMO Group Size Attestation	Fully insured	Small	English
Request for Certification of Disabled Dependent Premera HMO	Fully insured	Small, Large	English
Request for Certification of Disabled Dependent Premera HMO Spanish	Fully insured	Small, Large	Spanish
Solicitud de inscripción y cambios del miembro (Member Enrollment and Change Application	Fully insured	Large	Spanish
Waiver of Coverage HMO	Fully insured	Small, Large	English

Membership and billing

Form	Funding type	Group size	Language
Claim Reimbursement Request	All funding types	Individual, Small, Large	English
Deductible and Out of Pocket Credit	All funding types	Small, Large	English
Late Enrollment Acknowledgement	Fully insured	Small	English

Miscellaneous

Form	Funding type	Group size	Language
Affidavit of Domestic Partnership	All funding types	Individual, Small, Large	English
Authorization for Release of Psychotherapy Notes	All funding types	Individual, Small, Large	English
Authorization for Release of Summary Health Information - fully insured	Fully insured	Small, Large	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	Small, Large	English
Enrollment Center and Ebilling Authorization for Release of Detailed Group and Membership Information	All funding types	Small, Large	English
Information Release	All funding types	Individual, Small, Large	English
Non-Disclosure Request	All funding types	Individual, Small, Large	English
Non-smoker certification	All funding types	Individual	English
Request a Change in Your Records	All funding types	Individual, Small, Large	English
Request a Copy of Your Records	All funding types	Individual, Small, Large	English
Request a Record of Premera Disclosures	All funding types	Individual, Small, Large	English
Student Status Verification	All funding types	Individual, Small, Large	English
Summary of Contract Changes for Washington Small Groups	Fully insured	Small	English
Tobacco Use Certification	All funding types	Individual, Small, Large	English
Transition of Care	All funding types	Individual, Small, Large	English

Personal funding accounts

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

Pharmacy

Form	Funding type	Group size	Language
Express Scripts Health, Allergy & Medication Questionnaire	All funding types	Individual, Small, Large	English
Home Delivery Order Form	All funding types	Individual, Small, Large	English
Oral Chemotherapy Reimbursement	All funding types	Individual, Small, Large	English
Prescription Drug Reimbursement / Coordination of Benefits Claim Form	All funding types	Individual, Small, Large	English

Employer Forms

Everything you need - in one convenient place.

Group sales forms

Premera Blue Cross HMO forms

Membership and billing

Miscellaneous

Personal funding accounts

Pharmacy