Forms

Member appeal and authorization form - employer/group  (PDF document)
Formulario de apelación del miembro  (PDF document) (Member appeal and authorization form)
Note: Use this version if you have a Premera plan through your employer or another group.
Request an appeal of a decision or give your permission for another person to submitan appeal on your behalf.

Member appeal and authorization form - individual/family  (PDF document)
Formulario de apelación del miembro  (PDF document)(Member appeal and authorization form)
Note: Use these versions if you have an individual or family plan that you bought independently.
Request an appeal of a decision or give your permission for another person to submit an appeal on your behalf.

Member complaint form - employer/group  (PDF document)
Note: Use this version if you have a Premera plan through your employer or another group.
Senda complaint if you're unhappy and want to share your feedback with Premera.

Member complaint form - individual/family  (PDF document)
Note: Use this version if you have an individual or family plan that you bought independently.
Send a complaint if you're unhappy and want to share your feedback with Premera.

Independent Review Organization (IRO)  (PDF document)
These are external medical and contract experts not associated with Premera. We'll forward your request at no additional cost to you.Please complete the internal appeal process with Premera prior to submitting an IRO request.

Complaint and appeal rights  (PDF document)
Learn more about Premera's appeal process.

Complaint and appeal rights - individual plans  (PDF document)

Claim reimbursement form - Submit a medical claim for reimbursement when a healthcare provider is not submitting on your behalf.

• Employer-based and group-based plans, use this group claim form  (PDF document)
• Individual market health plans, use this individual claim form  (PDF document). *For flu shots and other vaccines, please use this form.

Dependent care manual claim form  (PDF document) - Reimbursements for expenses already incurred.

FSA/HRA expense manual claim form  (PDF document) - Get reimbursed for eligible out-of-pocket medical expenses if you have a flexible spending account (FSA) or healthreimbursement arrangement (HRA).

HSA expense manual claim form  (PDF document) - Get reimbursed for qualified out-of-pocket medical expenses if you have a health savings account (HSA).

Incident questionnaire  (PDF document) - Submit after sustaining an injury or being involved in an accident.

COVID-19 OTC home test reimbursement claim form  (PDF document) - Request reimbursement for COVID-19 tests you have paid for out of your own pocket.

Other coverage questionnaire  (PDF document) - Notify us that you have other coverage (such as medical, dental, prescription, vision or Medicare).

Information Release Forms:

Give someone permission to obtain and discuss your personal and health information, including sensitive information such as substance use disorder, 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.

Employer and group-based plans

Premera Blue Cross:
Information release form - employer/group  (PDF document)
Premera Blue Cross HMO:
Information release form - HMO employer/group  (PDF document)

Individual market health plans

Non-Disclosure Request

Request that we not share your personal health information with a specific person or entity.

Employer and group-based plans

Premera Blue Cross:
Non-Disclosure request - employer/group  (PDF document)
Premera Blue Cross HMO:
Non-Disclosure request - HMO employer/group  (PDF document)

Individual market health plans

Authorization for Release of Psychotherapy Notes

Allow access to notes made by medical professionals providing psychiatric or psychological services.

Employer and group-based plans

Premera Blue Cross:
Authorization for release of psychotherapy notes - employer/group  (PDF document)
Premera Blue Cross HMO:
Authorization for release of psychotherapy notes - HMO employer/group  (PDF document)

Individual market health plans

Disclosure Accounting Request

Request a record of how we disclose information about you for reasons other than our normal business functions.

Employer and group-based plans

Premera Blue Cross:
Disclosure accounting request - employer/group  (PDF document)
Premera Blue Cross HMO:
Disclosure accounting request - HMO employer/group  (PDF document)

Individual market health plans

Premera Blue Cross- individual/family:
Disclosure accounting request - individual/family  (PDF document)

Request for Amendment of Records

Change your official personal information record that we keep.

Employer and group-based plans

Premera Blue Cross:
Request for amendment of records - employer/group  (PDF document)
Premera Blue Cross HMO:
Request for amendment of records - HMO employer/group  (PDF document)

Individual market health plans

Premera Blue Cross - individual/family:
Request for amendment of records - individual/family  (PDF document)

Request for Inspection of Records

Request certain records we keep that contain your personal information.

Employer and group-based plans

Premera Blue Cross:
Request for inspection of records - employer/group  (PDF document)
Premera Blue Cross HMO:
Request for inspection of records - HMO employer/group  (PDF document)

Individual market health plans

Premera Blue Cross - individual/family:
Request for inspection of records - individual/family  (PDF document)

Confidentiality Request Form

Premera Blue Cross, Premera Blue Cross HMO, and individual/family:
Confidentiality request form
Request your protected health information be sent to you and choose how you receive it. Confidentiality form's request will remain in place until you revoke or modify it.
Note:

• Only applicable if you have:
  1. a Premera Blue Cross or Premera Blue Cross HMO fully-insured plan through your employer or another group (if you don't know whether your group plan is fully insured, ask your employer) OR
  2. a Premera individual plan you bought directly on the Washington state health exchange (the latter is only available through Premera Blue Cross).
• Requests to limit disclosure of your protected health information can be made through the non-disclosure request form instead.
• Requests to give permission for access to your personal health information can be made through the information release form instead.

Three ways to submit a confidentiality form to Premera Blue Cross and its affiliate Premera Blue Cross HMO by: email, regular mail, or phone.

Employer / group plans:

By email: AppealsDepartmentInquiries@premera.com

By regular mail:
Premera Blue Cross
PO Box 91102
Seattle, WA 98111

Premera Blue Cross HMO
PO Box 91102
Seattle, WA 98111

For members with individual plans for Premera Blue Cross:

By email through your secure web account. Sign into your account. Go to Contact Us > Send Email.

By regular mail:
Premera Blue Cross
PO Box 21702
Eagan, MN 55121

By calling customer service (phone number on the back of your ID card) to submit it verbally or have them submit it by email for you. Customer service can also help you change your contact information.

Individual and family plans

Domestic partner declaration individual plans  (PDF document)

HSA account application  (PDF document)
Open a health savings account (HSA).

Department of Retirement Service (DRS)  (PDF document)
Retired city employees on individual and family plans or Medicare plans can deduct their premium tax-free from their pensionincome.

Preventive services  (PDF document)
For plans with a start date on or after August 1, 2012.

Grandfathered plans

Standard health questionnaire  (PDF document)
A separate questionnaire must be completed for each family member.

Student status verification  (PDF document)
Verify with us that you are a full-time student.

Employer plans

Dental provider nomination form  (PDF document)

Affidavit of domestic partnership group plans  (PDF document)
Verify that your medical plan allows a domestic partner to be eligible for coverage on your plan.

Deductible credit form  (PDF document)
Verify deductibles applied toward plan members.

Request for certification of disabled dependent  (PDF document)
Declare that a member is financially responsible for their over-age dependent due to disability.
Request for certification of disabled dependent  (PDF document) (SEBB members)
Disabled Dependent Certification  (PDF document)(SEBB HMO members)
Certificacion de dependiente discapacitado  (PDF document) (Request for certification of disabled dependent - Spanish)

Waiver of coverage  (PDF document)
Decline coverage if offered.

Medicare Supplement automatic funds transfer authorization  (PDF document)
Authorize Premera to receive monthly fund transfers from your bank to pay for your individual health plan.

Member appeal and authorization form  (PDF document)
Request an appeal of a decision and/or give your permission for another person to submit an appeal on your behalf.

Member complaint form  (PDF document)
Send a complaint if you're unhappy and want to share your feedback with Premera.

Complaint and appeal rights  (PDF document)
Learn more about our appeal process.

Home delivery

Premera Blue Cross: Express Scripts pharmacy form  (PDF document)
Premera Blue Cross HMO: HMO Express Scripts pharmacy form  (PDF document)
Request home delivery of your medications.

Health, allergy and medication questionnaire

Premera Blue Cross: Drug interaction form  (PDF document)
Premera Blue Cross HMO: HMO Drug interaction form  (PDF document)
Complete this questionnaire for all new mail prescriptions to help protect yourself from potentially harmful side effects and medication interactions.

Oral chemotherapy reimbursement form

Out-of-network oral chemo form  (PDF document)
Use this form if you purchased oral chemotherapy drugs at an out-of-network pharmacy.

Direct reimbursement claims

Premera Blue Cross: Prescription drug reimbursement form  (PDF document)
Premera Blue Cross HMO: HMO Prescription drug reimbursement form  (PDF document)
Request reimbursement if you paid full price fora prescription at an out-of-network pharmacy.

Secondary coverage claims

Premera Blue Cross: Secondary insurance prescription drug claim form  (PDF document)
Premera Blue Cross HMO: HMO Secondary insurance prescription drug claim form  (PDF document)
Request reimbursement for the balance of your prescription costs if Premera is your secondary insurance.

Tax IRS form 1095-B

1095-B is a form you may need when you file taxes, depending on your state law.

Most members who have health plans through employers will not receive a paper copy of form 1095-B due to a tax law change. However, this form will continue to be available on our member website or by requesting a paper form.

How to get your tax form 1095-B:

• Sign in to your Premera account and go to My account and select Tax Form 1095 to find and/or download and print the form. Or go to Secure Inbox if you’d like to email your request to have the tax form mailed.
• Call the customer service phone number on the back of your ID card to request the form be mailed
• Mail in this filled-out form to the address on the back of your ID card:
  • Premera Blue Cross members: Fill out the 1095-B Mailing Request Form  (PDF document) and follow this document’s instructions for how to get a copy of the tax form
  • Premera Blue Cross HMO members, use this form: 1095-B Mail Request Form (HMO)  (PDF document)
  • Premera School Employee Benefits Board (SEBB) members who are not HMO members, use this form: 1095-B Mail Request Form (SEBB)  (PDF document)
  • Premera SEBB HMO members, use this form: 1095-B Mail Request Form (SEBB HMO)  (PDF document)

Inscripción de miembros y solicitud de cambios  (PDF document) (Member registration and change request)
Para cambiar informacion del miembro. (To change member information)

Cuestionario para inscripción en otras coberturas  (PDF document) (Questionnaire for enrollment in other coverage)
Para notificarnos de las otras coberturas. (To notify Premera of other coverage)

Formulario de apelación del miembro  (PDF document) (Member appeal and authorization form)
Solicite una apelación de una decisión y/o dé su permiso a otra persona para presentar una apelación en su nombre. (Request an appeal of a decision and/or give your permission to someone else to file an appeal on your behalf)

Formulario de divulgación de información  (PDF document) (Information disclosure form)
Dé su permiso a otra persona para obtener y analizar su información personal y de salud, incluida la información confidencial como abuso de sustancias, salud reproductiva y salud mental. También puede autorizar a los miembros de su plan para ver la información confidencial en Premera.como un cuenta de financiamiento personal.
(Give your permission to another person to obtain and analyze your personal and health information, including confidential information such as substance abuse, reproductive health, and mental health. You can also authorize your plan members to view confidential information on Premera.com or a personal funding account.)

Cuestionario del Incidente  (PDF document) (Incident questionnaire)
Envíanos está información después de sufrir una lesion o estar involucrado en un accidente (Send us this information after being injured or involved in an accident)

Certificacion de dependiente discapacitado  (PDF document) (Request for certification of disabled dependent)

Formulario de Pedido de Envío a Domicilio  (PDF document) (Express Scripts home delivery form)
Solicite la entrega a domicilio de sus medicamentos.

Formulario de Pedido de Envío a Domicilio HMO  (PDF document) (Express Scripts home delivery form - HMO)
Solicite la entrega a domicilio de sus medicamentos.