Employer Forms

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Request for rates small group
Census spreadsheet template

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

Group enrollment

• 2021 Group master application up to 50
• Fully Insured Group Master Application 51+
• Self-Funded Group Master Application 51+
• 2021 Group master application benefit selections up to 50
• Group master application benefit selections 51+ HRA
• Group master application benefit selections 51+ sharefund
• Group master application dental benefit selections up to 50
• Group size certification
• Late enrollment acknowledgement form
• Quick reference guide for plan administrators

Member enrollment

• Deductible credit form
• 2021 Small group member enrollment and change application
• 2020 Small group member enrollment and change application
• Inscripción de miembros de grupos pequeños y solicitud de cambios (Small group member enrollment and change application)
• Member enrollment and change application
• Inscripción de miembros y solicitud de cambios (Member enrollment and change application)
• HIPAA pre-existing change notice and instructions
• HIPAA: Período de espera para afecciones preexistentes (HIPAA pre-existing change notice and instructions)
• Other coverage questionnaire enrollment
• Cuestionario para inscripción en otras coberturas (Other coverage questionnaire enrollment)
• Request for certification of disabled dependent
• Waiver of coverage

Personal funding accounts

• 2021 Personal funding account setup form - for large groups
• 2021 Personal funding account setup form - for small groups
• 2022 Personal funding account setup form - for large groups
• 2022 Personal funding account setup form - for small groups
• Funding Account ACH Authorization
• CYC HSA Account Closure form
• CYC HSA Designation of Beneficiary form
• CYC HSA Trustee to Trustee Transfer form
• Personal funding accounts enrollment and change application
• HSA expense manual claim form

Member, other

Transition of care form

Form used for employer groups and multiple employer groups to report group size and Medicare beneficiary changes to Premera that may impact Medicare secondary payer (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 ConnectYourCare for personal funding accounts.
Authorization for release of psychotherapy notes
Disclosure accounting request
Non-disclosure request
Request for amendment of records
Request for inspection of records

Affidavit of domestic partnership group plans
Group eligibility adjustment form
Medicare prescription drug program non-creditable coverage notice
Preventive screening services (non-grandfathered plans)