Here you’ll find the most commonly used Premera member forms in Adobe .pdf format (unless otherwise noted). Don’t have Adobe Reader? Get it here
Tax Form 1095 may be needed to help you file your taxes. You can also find more details about Form 1095 on IRS.gov, or visit our Healthsource blog post on Form 1095.
Authorization for Appeals - Use this form to provide your approval for another party to submit an appeal on your behalf.
Member Appeal Form - Use this form to request an appeal of a decision.
Complaint and Appeal Rights - Learn more about Premera’s appeal process.For plans renewing October 1, 2010 or after, if you have questions regarding the appropriate appeal process for your plan, contact the customer service telephone number shown on the back of you I.D. card.
Dependent Care Account Claim Form
FSA/HRA Expense Manual Claim Form - Use this if you have an FSA (Flexible Spending Account) or HRA (Health Reimbursement Arrangement) to get reimbursed for eligible out-of-pocket medical expenses.
HSA Expense Manual Claim Form - Use this if you have an HSA (Health Savings Account) to get reimbursed for qualified out-of-pocket medical expenses.
Incident Questionnaire - Use after sustaining an injury or being involved in an accident.
Medical Claim Form - Submit a medical, or vision claim when the healthcare provider is not submitting it on your behalf.
Medical Claim Form (SERVICES OUTSIDE USA) - Submit a medical or vision claim when the healthcare provider is not submitting it on your behalf.
Other Coverage Questionnaire - Use to notify us that you have other coverage (such as medical, dental, prescription, vision or Medicare).
Authorization for Release of Psychotherapy Notes - Allow access to notes made by medical professionals providing psychiatric or psychological services.
Benefit and Claim Information Authorization Release - Use when release of benefit, claim, or personal information is required.
Disclosure Accounting Request - Request a record of how we disclose information about you for reasons other than our normal business functions.
Domestic Partner Information Sheet - Requirements about domestic partner eligibility.
Non-Disclosure Request - Tell us your requests about sharing your health information.
Request for Amendment of Records - Change your official personal information record that we maintain.
Request for Inspection of Records - Request certain records we maintain containing your personal information.
Individual and Family Plans - 2015 plans and after
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Automatic Funds Transfer Authorization - Authorize Premera to receive monthly fund transfers from your bank to pay for your individual health plan.
Complete List of Covered Dental Services
Group Plan - Member Enrollment and Change Application - Update member information such as adding a dependent.
HSA Authorization form UMB Bank
Individual Adult Dental Copay Application
Medical Provider Medical Necessity Certification - Treating physician should complete this form for a full-time student dependent who suffers a serious injury or illness and needs to reduce hours or take a leave of absence from school.
Other Coverage Questionnaire Enrollment - Provide information about other healthcare coverage you may have.
Preventive Services - For plans with a start date on or after August 1, 2012.
Tobacco Certification Form - For plans as of January 1, 2014 enrollment dates.
Application for the Addition of Family Members to an Individual Plan - Add family members to an existing individual plan (for grandfathered plans).
Non-Smoker Certification - Use if you and/or your spouse have been tobacco-free for 12 consecutive months prior to completing this form
Rate Brochure for Individuals and Families
Standard Health Questionnaire - A separate questionnaire must be completed for each family member.
Student Status Verification - Use to verify with us that you are a full-time student.
Affidavit of Domestic Partnership - Use this form if your medical plan allows a domestic partner to be eligible for coverage on your plan.
Deductible Credit Form - Verify deductibles applied toward plan members.
Member Enrollment and Change Application - Update member information such as adding a dependent.
Request for Certification of Disabled Dependent - Use to declare that a member is financially responsible for their over-age dependent due to disability.
Waiver of Coverage - Use this form to decline coverage if offered.
Discount Card Reimbursement - This form is only to be used for Affordable Care Act (ACA) Health Care Reform mandated prescription reimbursement for members on the Drug Discount Program.
Express Scripts Home Delivery Mail-Order Form - Order prescription drugs through the mail from Express Scripts.
Health, Allergy & Medication Questionnaire - Complete this questionnaire for all new mail prescriptions to help protect yourself against potentially harmful drug interactions and side effects.
Oral Chemotherapy Reimbursement Form - Oral Chemotherapy drugs purchased at an Out-of-Network pharmacy.
Prescription Drug Reimbursement - Apply for reimbursement of your prescription costs.
Secondary Insurance Prescription Drug Claim - Use for secondary reimbursement of your prescription costs balance where Premera is your secondary coverage.
Inscripcion del Miembro y Solicitud de Cambio - Para cambiar informacion del miembro.
Cuestionario para Inscripcion en Otras Coberturas - Para notificarnos de las otras coberturas.
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