Forms
If you are an active employee or retiree, please log on to your E-PEBP Portal for detailed information including Plan Year 2023 documents, new voluntary product information, to enroll/make changes, or to access your United Medical Resources (UMR) or Express Scripts single sign on accounts.
Eligibility Forms for All Plans:
- Insurance Marketplace Coverage Options for Eligible New Hires
- Insurance Marketplace Coverage Options for Ineligible New Hires
- Certification of Disabled Dependent Child
- Legal Guardianship Certification
- Release of Information Authorization
- Flexible Spending Enrollment Form
- Retiree Benefit Enrollment and Change Form
- Years of Service Form
- Benefit Enrollment and Change Form Unsubsidized
Appeal Forms:
- External Review Request Form
- Internal Claim Appeal Request Level 2
- Expedited Review
- Physician Certification of Experimental/Investigational Denials Form
Consumer Driven Health Plan Forms:
- Transition of Care and Continuity of Care for Sierra Health-Care Options
- OTC COVID-19 Testing Kit Reimbursement Form
- Diabetes Care Management Form
- Express Scripts RX Reimbursement Claim Form
- Express Scripts RX Mail Order Delivery Form
- UMR Medical Claim Form
- HRA Claim Form
- HSA Claim Form
- HSA Beneficiary/Spousal Consent Form
- HSA Contribution Form
- Obesity Care Management Initial Evaluation Form
- Travel Pre-Authorization for Organ/Tissue Transplant or Bariatric Surgery
- Travel Reimbursement Form for Organ/Tissue Transplant/Bariatric Surgery
Flexible Spending Account Forms:
- Flexible Spending Enrollment Form
- Health Care and Dependent Care Reimbursement Request Form
- Direct Deposit Authorization Form
Health Plan of Nevada (HPN) Forms:
- OTC COVID-19 Testing Kit Reimbursement Form
- Non-Plan Provider Claim Form
- Optum Pharmacy Mail Order Form
- Optum Pharmacy Reimbursement Form
Premier Plan (EPO) Forms:
- Transition of Care and Continuity of Care for Sierra Health-Care Options
- OTC COVID-19 Testing Kit Reimbursement Form
- Diabetes Care Management Form
- Express Scripts RX Reimbursement Claim Form
- Express Scripts RX Mail Order Delivery Form
- UMR Medical Claim Form
- Obesity Care Management Initial Evaluation Form
- Travel Pre-Authorization for Organ/Tissue Transplant or Bariatric Surgery
- Travel Reimbursement Form for Organ/Tissue Transplant/Bariatric Surgery
Low Deductible Plan Forms:
- Transition of Care and Continuity of Care for Sierra Health-Care Options
- OTC COVID-19 Testing Kit Reimbursement Form
- Diabetes Care Management Form
- Express Scripts RX Reimbursement Claim Form
- Express Scripts RX Mail Order Delivery Form
- UMR Medical Claim Form
- Obesity Care Management Initial Evaluation Form
- Travel Pre-Authorization for Organ/Tissue Transplant or Bariatric Surgery
- Travel Reimbursement Form for Organ/Tissue Transplant/Bariatric Surgery
Dental Plan Forms:
Basic Life Insurance Forms:
Effective 7/1/2022, UMR will be the plan administrator for the basic life insurance policy provided to eligible active and retired members.
The Standard Insurance Forms: