Medical and Vision Claim Forms

• UMP Medical Claim form (150K) Use this form for all services other than vision hardware and prescription drugs
• UMP Vision Hardware Claim form (105K) Use this form for eyeglasses & contacts

Prescription Drug Forms

Mail-Order Form

• Mail-Order Prescription Order Form (509K)

Paper Claims

• For prescriptions WA State Rx Services Drug Claim Form (770K)

See also: Instructions for submitting a prescription drug claim form

Other Forms

• Download a Claim Form For a Free Flu Shot (115K) (Where can I get my flu shot?)

Forms from PEBB:

• Employee enrollment/change
• Retiree forms
• Dependent Certification
  • Spouse or qualified domestic partner certification
  • Student certification/change
  • Certification of dependents with disabilities
  • Extended dependent certification
  • Adult Dependent Enrollment/Change
• Continuation of Coverage

To change your address or name, please see "How do I give Uniform Medical Plan my new address or new name?" below.

To obtain a Release of Information form, please call 1-800-762-6004.