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
Member appeal and authorization form - Request an appeal of a decision and/or give your permission for another person to submit an appeal on your behalf.
Independent Review Organization (IRO) - 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
Member complaint form - Send a complaint if you’re feeling unhappy and only wanting to share your opinion with Premera.
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 ID card.
Total Joint Replacement Exception Request (Washington small group, 1-50 employees) – Use this form if a (small group) member requests to use a provider and/or facility that isn’t a Premera-Designated Center of Excellence for total knee or hip replacement.
Dependent care account claim form - Reimbursements for expenses already incurred.
FSA/HRA expense manual claim form - Get reimbursed for eligible out-of-pocket medical expenses if you have a flexible spending account (FSA) or health reimbursement arrangement (HRA).
HSA expense manual claim form - Get reimbursed for qualified out-of-pocket medical expenses if you have a health savings account (HSA).
Incident questionnaire - Submit 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 - Notify us that you have other coverage (such as medical, dental, prescription, vision or Medicare).
Individual & family plans
Benefit and Claim Information Authorization Release Individual & Family
Health Care Information Non-Disclosure Request Individual & Family
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 (personal 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 (HSA).
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 - Certify that 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 - Verify with us that you are a full-time student.
Dental provider nomination form
Affidavit of domestic partnership group plans - Verify that 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 - Declare that a member is financially responsible for their over-age dependent due to disability.
Waiver of coverage - Decline coverage if offered.
Certificacion de dependiente discapacitado
Medicare supplement plans
Medicare supplement automatic funds transfer authorization - Authorize Premera to receive monthly fund transfers from your bank to pay for your individual
Discount card reimbursement
Drug discount program form - Get reimbursement for your prescription costs if you are a member of the Affordable Care Act's Drug Discount Program.
Express Scripts pharmacy form - Request home delivery of your medications.
Health, allergy and medication questionnaire
Drug interaction form - 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 - Use this form if you purchased oral chemotherapy drugs at an out-of-network pharmacy.
Direct reimbursement claims
Prescription drug reimbursement form - Request reimbursement if you paid full price for a prescription at an out-of-network pharmacy.
Secondary coverage claims
Secondary insurance prescription drug claim form - Request reimbursement for the balance of your prescription costs.
Inscripcion del miembro y solicitud de cambio - Para cambiar informacion del miembro.
Cuestionario para inscripcion en otras coberturas - Para notificarnos de las otras coberturas.
Apelación del miembro y formulario de autorización - Solicite una apelación de una decisión y/o dé su permiso a otra persona para presentar una apelación en su nombre.
Formulario de divulgación de información - 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.com o ConnectYourCare (cuenta de financiamiento personal).
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