WAHIT Members Forms Library


The following forms are provided for your assistance in submitting claims for your coverage under WAHIT.  For enrollment/disenrollment, waivers and deductible credit forms, please consult your employer.

Plan Description

Form

Premera Blue Cross Medical and Dental Forms

Request for Certification of Overage Dependent
For requesting certification of an overage (25+ years) dependent.  See your medical benefit booklet for more information.

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PBC RX Mail Order

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PBC RX Claim Form

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PBC Medical/Dental Claim

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VSP Vision Care Inc. Forms

USAble Supplemental Life Enrollment Form

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USAble Life Insurance Company Life and Disability Forms

USAble Supplemental Life Enrollment Form

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USAble Evidence of Insurability Form

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USAble Appeal Form

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USAble Beneficiary Change Form

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USAble Authorization for Release of Medical Records

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USAble Statement of Claim Group Accident Insurance

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USAble Application for Extended Insurance Benefits

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USAble Extended Life Insurance (Waiver of Premium) Update Form

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USAble Proof of Death Form

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USAble Accelerated Death Benefits Statement of Claim Form

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USAble Application for Portability of Group Term Life Form

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USAble Life Insurance Release of Absolute Assignment Form

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USAble Request for Conversion Form

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Domestic Partnership

Affidavit of Domestic Partnership

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