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 out-of-network provider services
- Vision claim form: including eyeglasses and contacts
- Medical Multiple Coverage Inquiry Form (Coordination of Benefits): if you have other medical coverage
- Incident Report Form: for accidental injuries
- 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 1-888-849-3681, or log in to your regence.com account.
- PPS Mail-Order Form: for mail-order pharmacy
- Release and Waiver Form, Ardon Health: for specialty drugs
- Washington State Rx Services Drug Claim Form
- Prescription Drug Multiple Coverage Inquiry Form
- Washington State Rx Services Complaint and Appeal Form
- Washington State Rx Services Authorization for Release of Information
All of the forms related to eligibility, enrollment, dependent certification, payroll deduction, and more are available on the PEBB Forms and publications page: