UMP (Regence) Authorization to Disclose Protected Health Information form

This form directs the Uniform Medical Plan's (UMP) administrator, Regence, to communicate with you about your personal health information (PHI).

Form

UMP (Regence) International medical claim form

This form is for sending in a claim for medical services received internationally for all Uniform Medical Plans (UMP) (Regence).

Form

UMP (Regence) Medical appeals and grievance form

This form may be included in an appeal or complaint, but is not required. It helps the member include all the necessary information for an appeal or complaint, and it includes the address and fax number where they should be submitted.

Form

UMP (Regence) Medical Claim Form

This medical claim form to send in a claim for medical services for all Uniform Medical Plans (UMP) (Regence).

Form

UMP (Regence) Medical incident report

This form is to report to Regence if an injury or illness may be covered under a third party. You may need to use this form even if the incident is not subject to third party coverage.

Form

UMP (Regence) Medical Preferred Drug List

This document is the Medical Preferred Drug List (PDL) for the Uniform Medical Plan (UMP). It lists prescription drugs covered by UMP under the medical benefit administered by Regence. This list applies to both PEBB and SEBB.

Publication

UMP (Regence) multiple coverage inquiry form

This form is to notify Regence that you have additional coverage under another medical plan.

Form

UMP (Regence) Programs to keep you healthy 2022

This document lists wellness programs offered by the Uniform Medical Plan (UMP) (Regence).

Publication

UMP (Regence) provider fee schedule January 2022

This is the Regence BlueShield fee schedule for providers.

Fee schedule

UMP (Regence) Quartet brochure

This brochure describes Quartet, a benefit that connects Uniform Medical Plan (UMP) members to behavioral health care.

Publication

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