Forms & publications

This form directs Washington State Rx Services (WSRxS) to communicate with you about your personal health information at the address you select. This form does not apply to your health care provider. You must give your provider separate, specific instruction about what health information they may share and with whom.

This form directs Washington State RX Services (WSRxS) to communicate with you about your personal health information at the address you select.

This form is for notifying Washington State Rx Services (WSRxS) that you have prescription drug coverage in addition to Uniform Medical Plan (UMP).

This claim form can be used to request reimbursement for over the counter COVID-19 at home tests.

These instructions outline how UMP members can access COVID-19 at home test kits from Costco pharmacy.

This is a Washington State Rx Services (WSRxS) claim form for reimbursement for prescription drugs for Uniform Medical Plan (UMP) members. Members might use this form if they purchased drugs at nonnetwork pharmacies or have other prescription coverage that pays first and UMP is secondary. Members might also use this form if they fail to show their ID at a network pharmacy or get a prescription from a mail-order or internet pharmacy other than Costco Mail-Order Pharmacy or Postal Prescription Services.

This Washington State Rx Services (WSRxS) form may be included in an appeal or complaint regarding prescription drug coverage, but it 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 documents should be submitted.