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 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
• Travel Reimbursement Form

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
• Express Scripts RX Reimbursement Claim Form
• Express Scripts RX Mail Order Delivery Form
• UMR Medical Claim Form
• Obesity Care Management Initial Evaluation Form
• Diabetes Care Management Form
• HSA Designation of Beneficiary Form 
• HRA Reimbursement Request Form
• HSA Direct Transfer Request Form
• Health Savings Account Application and Eligibility Form 
• Health Savings Account Direct Transfer Form 

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
• Express Scripts RX Reimbursement Claim Form
• Express Scripts RX Mail Order Delivery Form
• UMR Medical Claim Form

Low Deductible Plan Forms:

• Transition of Care and Continuity of Care for Sierra Health-Care Options
• OTC COVID-19 Testing Kit Reimbursement Form
• Express Scripts RX Reimbursement Claim Form
• Express Scripts RX Mail Order Delivery Form
• UMR Medical Claim Form

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.

• Accelerated Death Life Insurance Benefit
• Life Claim Form
• Waiver of Premium Form

The Standard Insurance Forms for Voluntary Life Insurance:

• Group Life Conversion Form
• Group Life Portability Form
• Life Insurance Claim Form

PEBP Vaccine Clinic Consent Form:

• Informed Consent for Immunization with Inactivated & Live Vaccines