These forms are for residents of all states except Alaska. If you want to find forms for Alaska, visit the Member Forms - Alaska page
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
Authorization for Appeals - Use this form to give your permission for another person 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 your I.D. card.
Dependent Care Account Claim Form - Use this for reimbursements for expenses already incurred.
FSA/HRA Expense Manual Claim Form - Use this if you have a flexible spending account or health reimbursement arrangement to get reimbursed for eligible out-of-pocket medical expenses.
HSA Expense Manual Claim Form - Use this if you have a 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.
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.
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.
Information Release Form - 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 (medical funding account.)
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 keep.
Request for Inspection of Records - Request certain records we keep that contain your personal information.
Individual and Family Plans - 2015 plans and after
Domestic Partner Declaration Individual Plans
Group Plan - Member Enrollment and Change Application - Update member information such as adding a dependent.
HSA Authorization form UMB Bank - Open a health savings account.
Department of Retirement Service (DRS) - Retired city employees on individual and family plans or Medicare plans can deduct their premium tax-free from their pension income.
Individual Adult Dental Copay Application
Medical Provider Medical Necessity Certification - Treating doctor 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.
Non-Smoker Certification - Use if you and/or your spouse have been tobacco-free for 12 consecutive months prior to completing this form
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.
Dental provider nomination form
Affidavit of Domestic Partnership Group Plans - 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.
Medicare Supplement Plans
Medicare Supplement Automatic Funds Transfer Authorization - Authorize Premera to receive monthly fund transfers from your bank to pay for your individual health plan.
Discount card reimbursement
If you are a member of the Affordable Care Act's Drug Discount Program, use this form for reimbursement of your prescription costs.
Drug Discount Program form
Request home delivery of your medications.
Express Scripts pharmacy form
Health, allergy and medication questionnaire
Complete this questionnaire for all new mail prescriptions to help protect yourself from potentially harmful side effects and medication interactions.
Drug interaction form
Oral chemotherapy reimbursement form
Use this form if you purchased oral chemotherapy drugs at an out-of-network pharmacy.
Out-of-network oral chemo form
Direct reimbursement claims
If you paid full price for a prescription because you didn't have your Premera card with you at an out-of-network pharmacy, you can request reimbursement.
Prescription drug reimbursement form
Download the Premera mobile app and you'll have proof of coverage at your fingertips.
Secondary coverage claims
Are you covered by more than one health plan, with Premera as your secondary coverage? If so, you can request reimbursement for the balance of your prescription costs.
Secondary insurance prescription drug claim form
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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