Forms available online
On this page
Note: Due to requirements regarding secure transmission of confidential information, we cannot post forms that may be filled and submitted online. However, you may print and complete the forms below and send via mail. Some may be filled in onscreen, then printed and mailed.
- Medical Claim Form: for services received from an out-of-network provider or if you have other insurance that pays first and UMP is secondary (see Submitting a claim)
- Vision Claim Form: for services from an out-of-network provider or for the purchase of prescription contact lenses and eyeglasses
- Medical Multiple Coverage Inquiry (Coordination of Benefits): if you and/or your dependents have other insurance
- Incident Report: for health care services related to an accident, injury, work-related condition, or possibly caused by another entity or individual.
- Appeals and Grievance Form: to help submit a complaint or appeal. However, this form is not required to submit an appeal.
To find a Release of Information form, call UMP Customer Service at 1-888-849-3681 (TRS: 711), or log in to your Regence account.
- Postal Prescription Services (PPS) Order Form: to order your prescription drugs through the mail
- Ardon Health Release and Waiver Form: for specialty medications ordered from Ardon Health
- Washington State Rx Services Prescription Drug Claim Form: for submitting your own prescription drug claim (see Submitting a claim)
- Prescription Drug Multiple Coverage Inquiry Form: if you and/or your dependents have other prescription drug coverage
- Washington State Rx Services Complaint and Appeal Form: to help submit a complaint or appeal. However, this form is not required to submit an appeal.
- Washington State Rx Services Authorization for Release of Information: to authorize the use or disclosure of your personal health information
Patient request for non-safety caps on prescription containers: use this form when purchasing specialty drugs through Ardon Health to request that Ardon Health not use child-resistant caps ("safety caps") to package your medication.
All of the forms related to eligibility, enrollment, dependent certification, payroll deduction, and more are available on the PEBB Forms and publications page:
UMP Customer Service
Business hours: Monday-Friday 5 a.m. to 8 p.m. and Saturday 8 a.m. to 4:30 p.m. Pacific time (PT)
Washington State Rx Services
Business hours: 24 hours a day, 7 days a week
Postal Prescription Services (PPS)
Business hours: Monday-Friday 8 a.m. to 7 p.m. and Saturday 8 a.m. to 12 p.m. PT
Business hours: Monday-Friday 8 a.m. to 5 p.m. PT