This section provides appeal information
Authorization for Appeals - Use this form to provide your approval for another party to submit an appeal on your benefit.
Member Appeal Form - Use this form to request an appeal of a decision
Complaint and Appeal Rights - Learn about your appeal rights
This section provides forms used for medical, dental claims
Dependent Care Account Claim Form
FSA/HRA Expense Manual Claim Form
HSA Expense Manual Claim Form
This section provides release of information forms
Authorization for Release of Psychotherapy Notes - Complete this form to allow access to notes made by medical professionals providing psychiatric or psychological services
Benefit and Claim Information Authorization Release - Use when release of benefit, claim, or personal information is required.
Disclosure Accounting Request - Use this form to request a record of how we disclose information about you for reasons other than our normal business functions.
Member Appeal Form - Use this form to request an appeal of a decision.
Member Appeal Process - Learn about your appeal rights.
Request for Amendment of Records - Change your official personal information we maintain using this form.
Request for Confidential Communication - Use this form to have your healthcare information sent to you instead of the person who pays for your health insurance plan. Please fill out the form and submit via fax, mail or email. Once we receive the form, we will send you an acknowledgement letter to let you know that we have received your request.
Mail: Member Appeals
PO Box 91102
Seattle, WA 98111-9202
Email: Contact Customer Service at 800-596-3440 for instructions
Non-Disclosure Request - Use this form to ask us not to share information with someone that you name because it could affect your safety.
Request for Inspection of Records - Use this form to request certain records that we maintain containing your personal information.
UMB HSA Account Application - An application to help set up an HSA bank account at UMB Bank
Authorization for Collection, Use and Disclosure of Personal Information for Underwriting and Enrollment
Application to Add Family Members to an Individual Plan - Use this form for plans starting prior to 1/1/14
Individual Policy Transfer Application (Direct Transfer Application)
Grandfathered and Extended Plans Dental Copay Listing
Grandfathered and Extended Plans Dental Sales Brochure
Case Management Referral Form
Coordination of Benefits Questionnaire
Deductible Credit Form
Medical Provider Medical Necessity Certification
Request for Certification of Disabled Dependent
Student Status Verification
Waiver of Coverage
Medicare Funds Transfer Form
Medicare Supplement Replacement Notice
Health, Allergy & Medication Questionnaire - Complete this questionnaire for all new mail prescriptions to help protect yourself against potentially harmful drug interactions and side effects.
Express Scripts Home Delivery Mail-Order Form - Want your prescription drugs delivered directly to you at home? Use this form.
Prescription Drug Reimbursement Form - Apply for reimbursement of your prescription costs
Secondary Coverage Claim Form - Are you covered by more than one health plan, with LifeWise as your secondary coverage? If so, you can request reimbursement for the balance of your prescription costs.