For your convenience, we've categorized our most frequently used forms.
If you can't find the form you need or require further assistance, please contact us.
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
HSA Authorization Form for UMB Bank
Domestic Partner Declaration Individual Plans
Individual Select Dental Plan for Adults application
HSA Authorization Form form UMB Bank
Tobacco Certification Form - For plans as of 1/1/2014 enrollment dates
Preventive Screening Services - For plans with a start date on or after Aug. 1, 2012
Standard Health Questionnaire - A separate questionnaire must be completed for each family member
Preventive Screening Services - For grandfathered plans
Express Scripts Home Delivery 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.
Oral Chemotherapy Reimbursement Form - This form is only to be used for plans that do not have out-of-network prescription coverage.
Authorization for Release of Healthcare Information and Records
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
Producer of Record Change Form
Our small group page has forms and other materials available to producers.
Our large grouppage has forms and other materials available to producers.
Health, Allergy & Medication Questionnaire - Complete this questionnaire for all new mail prescriptions to help protect yourself against potentially harmful drug interactions and side effects.
Self-Funded Health Plan Authorized Representative Disclosure Form
Student Status Verification
Summary Health Information Authorization for Insured Groups
Small Group General Agency of Record Change Form