NOTE: Due to requirements regarding secure transmission of confidential information, we cannot post forms that may be filled and submitted online. However, you may print and complete the forms below and send via mail. Some may be filled in onscreen, then printed and mailed.

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Medical Forms
Medical Claim form PDF (236K) (for out-of-network provider services)
See instructions for when and how to submit a medical claim
Vision Claim Form PDF (268K) (including eyeglasses and contacts)
Coordination of Benefits (Multiple Coverage Inquiry Form) PDF (247K)
Incident Report Form PDF (327K) (for accidental injuries)

To obtain a Release of Information form, call 1-888-849-3681, or log in to your account.

For an appeals form, you may log in to your account* and search for "appeals." However, you do not need a form to submit an appeal. See instructions for submitting appeals.

*This is an external site that requires registering for a personal online account.

See also instructions for submitting medical (non-prescription) claim forms.

Prescription Drug Forms

Mail-Order Pharmacy

PPS Mail-Order Form PDF (1.1MB)
Specialty Drugs
Release and Waiver Form, Ardon Health PDF  (426K)

Retail Pharmacies

WA State Rx Services Drug Claim Form PDF (111K)

See also Instructions for submitting a prescription drug claim form

Multiple Coverage

Prescription Drug Multiple Coverage Inquiry Form PDF

Prescription Drug Appeals and Complaints

WA State Rx Services Complaint and Appeal Form PDF (50K)
WA State Rx Services Authorization for Release of Information PDF (32K)

Health Savings Account (HSA) Form

Employee Authorization for Payroll Deduction to Health Savings Account (2016) (2017) PDF

Eligibility and Enrollment Forms from PEBB

  • Employee enrollment/change form
  • Retiree forms
  • Dependent Certification forms
  • Continuation of Coverage forms
  • Forms to deduct premiums from your bank account

ALERT! Eligibility and enrollment issues are handled by the PEBB Program; seethe PEBB home page or call at 1-800-200-1004.

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