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 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.
- Disclosure Authorization form: to provide authorization to disclose protected health information.
- International Claim form: 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.
- Prescription Drug Reimbursement Claim form: for prescription drugs you paid out of pocket and are seeking reimbursement for (see Submitting a claim).
- ArrayRx Multiple Prescription drug coverage inquiry form (coordination of benefits): if you and/or your dependents have other prescription drug coverage.
- ArrayRx Complaints and Appeals form: to submit a complaint or appeal. However, this form is not required to submit an appeal.
- ArrayRx Authorization for Release of Information for UMP (PEBB and SEBB) members: to provide ArrayRx authorization to disclose protected health information.
- ArrayRx 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 ArrayRx, Ardon Health, or Postal Prescription Services (PPS).
If you have questions about this form, contact your payroll or benefits office.
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.
ArrayRx, Postal Prescription Services and Ardon Health do not provide BlueCross BlueShield services and are separate companies solely responsible for their product/services.
VSP is a separate company that provides vision services.