Commonly used forms - PEBB

UMP commonly used forms available online

UMP commonly used forms are available online. 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 to the address listed on the form. Some may be filled in onscreen, then printed and mailed.

 Medical forms

If you have questions about a form, call UMP Customer Service.

 Vision form

If you have questions on how to fill out this claim form, contact VSP Member Services at 1-800-877-7195. Deaf, DeafBlind, Late Deafened and Hard of Hearing members call: 1-800-428-4833.

 Prescription drug forms

If you have questions about a form, contact Washington Rx Services (WSRxS), Ardon Health, or Postal Prescription Services (PPS).

 Health Savings Account (HSA) form
 Eligibility and enrollment forms

All of the forms related to eligibility, enrollment, dependent certification, payroll deduction, and more are available on the Employee and Retiree Benefits Forms and publications page.

Washington State Prescription Services does not provide BlueCross BlueShield services and is a separate company solely responsible for its product/services.

VSP is a separate company that provides vision services.