Regence & Asuris Forms Library

FORMS LIBRARY

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

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 (Download)
Regence/Asuris: Rx Home Delivery Form (Download)