FORMS LIBRARY This section will allow you to access forms for Regence BlueShield and Asuris Northwest.


2021 Plan Year
(January 1, 2021 to December 31, 2021)


Medical Forms (Regence BlueShield / Asuris Northwest Health)
  • Regence/Asuris Domestic Partner Affidavit (Regence) (Asuris)
  • Cambia Health Solutions HSA Health Equity Banking Agreement (Download)
  • Regence/Asuris Member Reimbursement Claim Form (Download)
  • Regence/Asuris Authorization to Disclose Protected Health Information (Download)
  • Group Size Certification Form (Regence) (Asuris)
  • Verification of Employment for Micro Groups (Download)
  • Regence: Owner Verification Form (Download)
  • Regence: Renewal & Maintenance Change Request Form (Download)
  • Regence: Group Change Notification Form (Download)
  • Regence: Affidavit of Qualifying Incapacitated Dependent Eligibility - Individual Coverage (Download)


*No changes made to the forms from the 2019 Plan Year.



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