Find a Form or Document


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.

 



Forms

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)
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
Direct Draft Form
Disabled Dependent Eligibility Application
Electronic Funds Transfer Form
ESRD Initial Screening Form
Health Benefits Enrollment Form (Complete Online)
HealthCheck Forms
Healthy Tomorrows Reporting Form (Plan Year 2018)
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)