NOTE: Due to requirements regarding secure transmission of confidential information, we cannot post forms that may be filled and submitted online.

Medical Forms

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

See also instructions for submitting non-prescription claim forms.

Prescription Drug Forms

Mail-Order Pharmacy

Retail Pharmacies

See also Instructions for submitting a prescription drug claim form

Multiple Coverage

Prescription Drug Appeals and Complaints

Health Savings Account (HSA) Form

Eligibility and Enrollment Forms from PEBB

  • Employee enrollment/change form
  • Retiree forms
  • Dependent Certification forms
  • Continuation of Coverage forms

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