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.
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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 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
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 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
Transition of care form
HRA electronic funding authorization
Funding Account ACH
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
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)