Producer Forms

Individual and family plans

Domestic partner declaration individual plans

Tobacco certification form - For plans as of 1/1/2014 enrollment dates

Preventive screening services - For plans with a start date on or after 8/12/2012

Grandfathered plans

Preventive screening services - For grandfathered plans

Non-smoker certification

Medical and Dental Claims

Claim form

Pharmacy

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.

Personal funding accounts

HSA Account Closure Form

HSA Designation of Beneficiary Form

HSA Trustee to Trustee Transfer Form

Disclosure and privacy

Authorization for release of psychotherapy notes

Disclosure accounting request

Non-disclosure request

Request for amendment of records

Request for inspection of records

Miscellaneous

Affidavit of domestic partnership group plans

Group enrollment (up to 50 employees)

2024

• 2024 Small Group Master Application up to 50
• 2024 Small Group Benefit Selection Worksheet up to 50 - Medical
• 2024 Small Group Benefit Selection Worksheet up to 50 - Dental
• 2024 Small Group Master Application up to 50 Premera Blue Cross HMO
• 2024 Small Group Benefit Selection Worksheet up to 50 Premera Blue Cross HMO

Additional group enrollment forms

• New group enrollment checklist
• Renewal group enrollment checklist
• Group size attestation
• 2024 Small Group Size Attestation for Premera HMO
• Late enrollment acknowledgement
• Late Enrollment Acknowledgement form for Premera HMO
• Quick reference guide for plan administrators
• Enrollment Exception Request Form

Member enrollment and other forms

• Member Enrollment & Change Application - English
• Inscripción de miembros de grupos pequeños y solicitud de cambios (Small Group Member Enrollment and Change Application)
• Member Enrollment & Change Application HMO - English
• Inscripción de miembros de grupos pequeños y solicitud de cambios HMO  (Small Group Member Enrollment and Change Application HMO)
• Affidavit of domestic partnership group plans
• Deductible credit form
• Enrollment spreadsheet (in lieu of member enrollment applications)
• Other coverage questionnaire enrollment
• Request for certification of disabled dependent
• Waiver of coverage
• Transition of care form

Personal funding accounts

• Personal funding account setup form - small groups
• Funding Account ACH Authorization
• HSA Account Closure form
• HSA Designation of Beneficiary form
• HSA Trustee to Trustee Transfer form
• Personal funding accounts enrollment and change application
• Funding Account Employer Admin Guide  - small groups

Group enrollment (51+ employees)

• 2024 Group master application 51+ fully insured
• 2024 Group Master Application - Self-funded
• 2024 Group Master Application - OptiFlex
• 2024 Group master application 51+ for Premera HMO
• Group size certification
• Late enrollment acknowledgement
• Quick reference guide for plan administrators
• Enrollment Exception Request Form

Member enrollment

• Member Enrollment & Change Application
• Inscripcion de Miembros de Grupos y Solicitud de Cambios (Member Enrollment & Change Application)
• Member Enrollment & Change Application HMO
• Inscripcion de Miembros y Solicitud de Cambios HMO (Member Enrollment and Change Application HMO)
• Deductible credit
• Enrollment spreadsheet (in lieu of member enrollment applications)
• Other coverage questionnaire enrollment
• Request for certification of disabled dependent

Member, other

• Waiver of coverage
• Waiver of Coverage - Premera HMO
• Dental provider nomination form
• Transition of care

Personal funding accounts

• Personal funding account setup form - large groups
• Funding Account ACH Authorization
• HSA Account Closure form
• HSA Designation of Beneficiary form
• HSA Trustee to Trustee Transfer form
• Personal funding accounts enrollment and change application
• Funding Account Employer Admin Guide - large groups

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.

Summary Health Info Authorization for Self-Funded PBC

Summary Health Info Authorization for Insured Groups PBC

Summary Health Info for Insured Group Premera HMO

Authorization for Release of Psychotherapy Notes

Disclosure Accounting Request

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 a personal funding account.

Non-Disclosure Request

Request for Amendment of Records

Request for Inspection of Records

• Affidavit of Domestic Partnership Group Plans
• Student Status Verification
• Summary Health Information Authorization for Insured Groups
• Small Group General Agency of Record Change Form