Insurance Forms

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All forms are in Adobe Acrobat (pdf) format. If you do not have this program on your computer, click on the Acrobat Reader icon and follow the directions on how to download this program for free. Once you have downloaded the program, you will have to open it to install. You will then be able to view and print out these forms.

Medical Forms - WEA/Premera Blue Cross Select Plan 2
Subscriber Claim	Premera Blue Cross
Prescription Claim	Premera Blue Cross
COBRA Continuation of Coverage	Premera Blue Cross
Waiver of Coverage	Premera Blue Cross
Deductible Credit	Premera Blue Cross
Medical Forms - KPS Health Plans
Open Enrollment Waiver Form	KPS Health Plans
COBRA Continuation Election Form	KPS Health Plans
Privacy Notice	KPS Health Plans
Information Disclosure	KPS Health Plans
Mental Health Q & A	KPS Health Plans
Medical Forms - Aetna Health
Medical Claim Form	Aetna Health
Prescription Drug Claim	Aetna Health
Medical Forms - Group Health
	Group Health
Medical Forms - PacifiCare
Prescription Drug Reimbursement Form	PacifiCare
Dental Forms - Washington Dental Service
Dental Claim	Washington Dental Service
Basic Life/AD&D Forms - Standard Insurance Company
Waiver of Premium Claim	Standard Insurance Company
Proof of Death Claim	Standard Insurance Company
Accidental Dismemberment	Standard Insurance Company
Accelerated Benefits Claim	Standard Insurance Company
Survivor Income Claim	Standard Insurance Company
Long Term Disability Claim	Standard Insurance Company
Flexible Spending Account - Flex Plan Services
Flexible Spending Account Claim Form	Flex-Plan Services
FSA Change of Status Form	Flex-Plan Services