Member appeal and authorization form - Request an appeal of a decision and give your permission for another person to submit an appeal on your behalf.
Complaint and appeal rights - Learn about your appeal rights.
Claim form - Need to file a claim? Start here.
FSA/HRA expense manual claim form - Get reimbursed for eligible out-of-pocket medical expenses if you have a flexible spending account (FSA) or a 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 - Complete this form after sustaining an injury or being involved in an accident.
Dependent care account claim form
Other coverage questionnaire - Provide information about other coverage you may have.
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.
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 LifeWiseWA.com or ConnectYourCare (personal funding account).
Non-disclosure request form - Tell us your requests concerning sharing your health information.
Request for amendment of records - Change your official personal information we maintain using this form.
Request for inspection of records - Request certain records that we maintain containing your personal information.
For metallic plans
Declaration of domestic partnership
Individual adult dental copay plan - Add adult dental coverage to an individual metallic plan.
UMB HSA account application - Set up an HSA bank account at UMB Bank.
Tobacco certification form - For plans as of 1/1/14 enrollment dates.
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.
Application for the addition of family members - Add family members to an existing policy. For grandfathered plans.
Standard health questionnaire - For plans effective with enrollment date on or after March 23, 2012.
Non-smoker certification - This form is to be completed when subscriber and/or spouse/domestic partner has not used tobacco products 12 months preceding submittal of this form.
Grandfathered plans dental copay listing
Grandfathered plans dental sales brochure
Employers in Clark County
Affidavit of domestic partnership - Verify a domestic partnership.
Case management referral form - Make a case management request.
Deductible credit form - Verify deductibles applied toward plan members.
Waiver of coverage - Decline coverage by an employee.
Member enrollment and change application - Enroll an employee as a member.
Member enrollment and change application (Spanish version) - Spanish version of the form used to enroll an employee as a member.
Group master application 51+ - For Clark County only.
Disabled dependent request for certification - This form is filed by the employee to enroll a disabled dependent.
Discount card reimbursement - Get reimbursement for your prescription costs if you are a member of the Affordable Care Act's Drug Discount Program.
Prescription drug reimbursement - Get reimbursement for your prescription costs.
Express Scripts mail-order form - Request home delivery of your medications.
Health, allergy & medication questionnaire - Complete this questionnaire for all new mail prescriptions to help protect yourself against potentially harmful drug interactions and side effects.
Secondary coverage claim form - Request reimbursement for the balance of your prescription costs.
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