Washington State Health Care Authority Forms

This form is used for requesting prior authorization for buprenorphine monotherapy in Washington.

This Form is used for individuals or organizations applying for membership to the Health Technology Clinical Committee in Washington.

This form is used for providing a medical history statement for the School Employees Benefits Board Program in Washington. It is required to provide evidence of insurability for school employees.

This form is used for enrolling in or making changes to long-term disability insurance in the School Employees Benefits Board (SEBB) Program in Washington state.

This Form is used for disenrolling from the Pebb Medicare Advantage Plan in Washington.

This form is used for enrolling in the Pebb Medicare Advantage Plan in Washington.

This Form is used for obtaining authorization to disclose protected medical information in Washington state. (Note: This information is in Spanish)

This form is used for UMP members in Washington to appeal a decision made by their healthcare provider.

This Form is used for submitting an inquiry regarding multiple coverage in the state of Washington.

This document is used for attesting to the chronic use of opioids in the state of Washington.

This form is used for inquiring about multiple pharmacy coverage in the state of Washington.

This form is used for filing prescription drug claims in the state of Washington. It allows individuals to seek reimbursement for the cost of prescribed medications.

This form is used for enrolling school employees in Washington state.

This form is used for adding additional dependents to the Sebb employee health plan in the state of Washington.

This form is used for notifying the enrollment extension for supplemental life insurance in Washington through the SEBB program.

This Form is used for making changes to school employee information in the state of Washington.

This form is used for school employees in Washington to enroll additional dependents in the health care plan.

This form is used for making corrections to the Sebb Long-Term Disability (Ltd) Insurance application in Washington state.

This document is an example of a Contact Log and Unit Tracking form used in Washington state. It helps to keep track of contact information and unit details efficiently.

This Form is used for patients to attest their connection with oral health services in Washington.

This Form is used for notifying the Sheriff or Chief of Police in Washington State about the suspension of firearm rights for a period of six months under RCW 71.05.182