Forms & publications

Can't find what you need? Visit UMP Forms and publications for more documents.

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

Medical Multiple Coverage Inquiry Form (Medical Coordination of Benefits)

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

Form

Medicare Advantage disenrollment form (form D) 2019

51-556-2019

Use this form to disenroll from Medicare Advantage.

Form

Medicare Advantage plan election form (form C) 2019

51-576-2019

Use this form to enroll in Medicare Advantage plans.

Form

Medicare benefits comparison 2019

This chart briefly compares the per-visit costs of some in-network benefits for PEBB plans. Some copays and coinsurance do not apply until after you have paid your annual deductible. Call the plans directly for more information on specific benefits, including preauthorization requirements and exclusions. Kaiser Permanente NW and Kaiser Permanente WA offer Medicare Advantage plans, but not in all areas.

Publication

Medicare supplement plan F benefits 2019 (outline)

Outline of Medicare Supplement Plan F Coverage. Shows the benefits included in each of the standard Medicare supplement plans.

Publication

Memorandum of understanding

Memorandum of understanding between HCA and an employer group.

Form

MetLife beneficiary designation

Use this form to name the persons or entities you want to receive your life insurance proceeds after your death. Return this form to MetLife.

Form

MetLife cancellation of life insurance - retiree

51-857

Use this form to notify MetLife that you wish to cancel your Retiree Life Insurance. If you cancel your Retiree Life Insurance, you may not reenroll in life insurance unless you regain eligibility for life insurance at a later date.

Form

MetLife cancellation of optional life insurance form - employee

Use this form to notify MetLife that you wish to cancel your Optional Life Insurance and/or Optional Accidental Death & Dismemberment (AD&D) Insurance. For employees only: Employee Basic Life Insurance ($35,000) and Employee Basic AD&D Insurance ($5,000) is not affected by this form. It is provided by your employer at no cost to you. You cannot cancel your Employee Optional Life Insurance and keep Dependent Life Insurance.

Form

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