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Find a Form

The following is an alphabetical list of forms and documents on the Web site.

If you see (Complete Online) next to a form, you can do this online by going to Manage My Benefits. It's easier, faster and leads to fewer mistakes than printing a form and sending it to PEIA.


ABA Services Authorization Form
ABA Services Preauthorization Form
Allergy Test Precertification Form
Annual Routine Physical and Screening Examination Form
Authorization to Remove Coordinator Form
Basic and/or Optional Life Insurance Change of Beneficiary Form (Complete Online)
Basic Life Insurance Enrollment Form (Complete Online)
Bayer Meter Request Fax Order Form
Benefit Coordinator Supply Order Form
Change-in-Address Form (Complete Online)
Change-in-Status Form (Complete Online)
CKD Initial Screening Form
Comprehensive Care Program Enrollment Form
Coordination of Benefits Form
Court-Ordered Dependent Claim Packet
Dependent Out of Area Benefit Form
Direct Draft Form
Discount Waiver Request Form
Disabled Dependent Eligibility Application
Drug Formulary Inquiry Form
Electronic Funds Transfer Form
Employer's Authorization to Remove PEIA Coordinator
ESRD Initial Screening Form
Health Benefits Enrollment Form (Complete Online)
HealthCheck Forms (go to "Provider Information")
Healthy Tomorrows Reporting Form
HIPAA Authorization Form
Mainframe Access Request Form
Medical Claim Form
Medical Home Application and Physician Selection Form
Medical Home ID Card Request Form
Medical Home Payment Information Form
Medical Home Provider Enrollment Form
Medical Travel Expense Reimbursement Request Form
Mountaineer Flexible Benefits Enrollment Form (Active Employees)
Mountaineer Flexible Benefits Enrollment Form (Retirees)
Notice of Death Form
Optional Life Insurance and Dependent Life Insurance Enrollment Form (Complete Online)
Patient Audit Form
Pick a PCP Form
Premium and Benefit Assistance Form (non-Medicare)
Premium and Benefit Assistance Form (Medicare)
Prescription Drug Claim Form
Prescription Drug Claim Form (foreign)
Provider Demographic Worksheet
Provider Request for More Information Form
Request for Prior Approval of Services Form
Retired Employee's Optional and Dependent Life Insurance Enrollment Form
Retirement Health Benefits and Basic Life Insurance Enrollment Form
Sample CCP Provider Contract 
Surviving Dependents Health Benefits Enrollment Form

Suspected Insurance Fraud Citizen Reporting Form
Transition of Care Form
Termination Form (Complete Online)
Tobacco Affidavit (Complete Online)
Waiver of Premium Forms


Beneficiary Financial Counseling Brochure
Beneficiary Financial Counseling Poster
Benefit Coordinators Reference Manual
CareEngine Slide (5-19-09)
Case Managed Drugs
Common Specialty Medications
Comprehensive Care Program Provider Manual
Directions to PEIA
Eligibility Documentation Memo
Employee Reconciliation and Dependent Eligibility Verification Audits (3-23-11)
Explanation of Benefits (sample)
FAQs about Medicare Retiree Changes
FAQs on Will Preparation and Beneficiary Financial Counseling Services
FAQs Small Business Health Insurance Plan
Face to Face Diabetes Management Brochure
Healthy Tomorrows Beyond Pick a PCP
Healthy Tomorrows Frequently Asked Questions
Healthy Tomorrows in a Nutshell
Healthy Tomorrows Information for Managers
Healthy Tomorrows Pick a PCP
H1N1 (Swine Flu) Virus Fact Sheet
High-Performance Preferred Drug List (Plans A, B and C)
High-Performance Preventative Drug List (Plan C)
High-Performance Drug Formulary Top Indications
High-Performance Drug List Changes (11-1-14)
High-Performance Formulary Tier Listing
Life Insurance Benefits Booklet
Living Will Affidavit Cover Letter (12-10)
Maintenance Medications List
Medical Home Cover Letter
Medicare Advantage Fact Sheet
Medicare Advantage Flyer
Medicare Advantage Letter (9-09)
Medicare Advantage Plan Booklets
Medicare Advantage Preauthorization and Notification List
Medicare High-Performance Drug Formulary
Medicare Shopper's Guides
Mountaineer Flexible Benefits Plan (Active Employees)
Mountaineer Flexible Benefits Plan (Retirees)
Nicotine Replacement Therapies
Notice of Privacy Practices
OPEB Plan Participation Standards
Outpatient Hospital Prospective Payment Billing Manual (2-1-08)
PPS Billing Manual (7-1-06)
Premium Conversion Plan Information
Prior Authorization/Drugs with Special Limitations
Provider Directory
RBRVS Manual (1-1-09)
Retail Maintenance Network
River Valley Health Alliance Termination Letter
Shopper’s Guides
Special Medicare Plan Booklets
Summary Plan Descriptions
Tier 3 Drugs Copayment Change
Washington County Provider Network
Wells Fargo TPA and HealthSmart FAQs
Weight Management Brochure
Will Preparation Services Brochure
Will Preparation Services Flyer
Will Preparation Services Poster

Other Information

Fee Schedules & Manuals
Financial Reports
Health & Wellness
Health Tips
Historic Fee Schedules
Premium Rates
Requests for Proposals / Requests for Quotations

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