UMP commonly used forms available online

• Medical Reimbursement 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 How to submit a claim).
• Multiple Coverage Inquiry (Coordination of Benefits) form: if you and/or your dependents have other insurance.
• Incident Report form: 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.
• The Disclosure Authorization form is to provide authorization to disclose protected health information.
• The International Claim form is to be used to submit medical institutional and professional claims for benefits for covered services received outside the United States, Puerto Rico, and the U.S. Virgin Islands.
  

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

• VSP Request for Reimbursement form: for services from an out-of-network provider or for the purchase of prescription contact lenses and eyeglasses.

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: (TTY) 1-800-428-4833.

• Prescription Drug Reimbursement Claim form: for prescription drugs you paid out of pocket and are seeking reimbursement for (see Submitting a claim).
• WSRxS Multiple Prescription drug coverage inquiry form (coordination of benefits): if you and/or your dependents have other prescription drug coverage.
• WSRxS Complaints and Appeals form: to submit a complaint or appeal. However, this form is not required to submit an appeal.
• WSRxS Authorization for Release of Information for UMP (PEBB and SEBB) members: to provide WSRxS authorization to disclose protected health information.
• WSRxS Provider Attestation form for Prescribing Opioids
• Ardon Health Disclosure Authorization form: to provide Ardon Health authorization to disclose protected health information on specialty drugs.
• Ardon Health Specialty Drugs – request for non-safety caps on prescription containers form: when purchasing specialty drugs from Ardon Health, use this form to request that Ardon Health not use child-resistant caps ("safety caps") to package your medication.
• Ardon Health Specialty Drugs – Delivery signature release and waiver form
• PPS Mail-order pharmacy form: to register and order your prescription drugs through Postal Prescription Services (PPS).

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

• Employee Authorization for Payroll Deduction to Health Savings Account

If you have questions about this form, contact the Public Employees Benefits Board (PEBB) Program.

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.