Forms

Enrollment Forms

Claim Forms

Dental Claim Form (for Active Participants and Retirees Enrolled in the Dental Plan)

Medical/Rx Claim Form – For Active and COBRA, and Non-Medicare Retirees

Costco Health Solutions Reimbursement Claim Form

Time Loss Claim Form

Vision Service Plan (VSP) Non-Network Claim Reimbursement Form

Privacy and Disclosures

Authorization for Disclosure of Protected Health Information

Health & Security Trust – Notice of Privacy Practices

Revocation of Protected Health Information Disclosure

Preauthorization

Required for outpatient surgeries and imaging services and for all inpatient services and before hospital admission or within 48 hours of emergency admission. Call Innovative Care Management at 1-800-862-3338.

Where to send completed Medicare Retiree Medical claim forms, Dental claim forms and Retail RX claim forms:

Administration Office
P.O. Box 34464
Seattle, WA 98124-1464

Where to send completed Weekly Disability Benefits claims and all other completed forms:

Administration Office
P.O. Box 34203
Seattle, WA 98124-1203