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

Group master application up to 50

Fully Insured Group Master Application 51+

Self-Funded Group Master Application 51+

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

Group verification of medicare coverage

Late enrollment acknowledgement form

Quick reference guide for plan administrators

Member enrollment

Deductible credit form

Small group member enrollment and change application

Small group member enrollment and change application (Spanish version)

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

Personal funding accounts, UMB Bank forms

Personal funding accounts enrollment and change application

Personal funding account setup form - for small groups

Personal funding account setup form - for large groups

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

Member, other

Transition of care form

HRA electronic funding authorization

Funding Account ACH Authorization

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)