West Virginia Public Employees Insurance Agency Forms
The West Virginia Public EmployeesInsurance Agency (PEIA) is a state agency that provides health insurance coverage to public employees and their dependents in West Virginia. PEIA offers a range of health insurance plans and benefits to eligible participants, including medical, dental, and vision coverage, as well as prescription drug benefits. Its primary purpose is to ensure that public employees and their families have access to affordable and comprehensive health insurance.
Documents:
46
This document grants authority to an individual to act on behalf of another person according to West Virginia law.
PDF 
Word
This form is used for creating a medical power of attorney and living will in West Virginia. It allows individuals to appoint someone to make medical decisions on their behalf and express their preferences for end-of-life care.
This document is used for making demographic changes to the Mountaineer Flexible Benefits program for active employees in West Virginia.
This Form is used for enrolling in health benefits through the State of West Virginia Public Employee Insurance Agency.
This form is used for reporting a change in status in the state of West Virginia. It is used for updating personal information or notifying a change in circumstances.
This Form is used for enrolling dependents for health coverage in West Virginia.
This form is used for a policyholder in West Virginia to terminate their coverage.
This document is for applying for eligibility of disabled dependents in West Virginia.
This Form is used for enrolling in the Comprehensive Care Partnership (CCP) Program in West Virginia.
This form is used for requesting dependent out-of-area benefits in West Virginia.
This Form is used for submitting claims by members in West Virginia for various types of insurance coverage.
This Form is used for requesting a discount waiver in West Virginia.
This document is used for facilitating the transition of care for patients in West Virginia. It helps to ensure that relevant medical information is accurately and efficiently transferred between healthcare providers.
This document is used for requesting prior approval of services in the state of West Virginia. It is a form that must be completed in order to receive authorization for specific services.
This type of document is used for conducting a patient audit in West Virginia. It helps gather information about patient care and ensure compliance with regulations.
This form is used for updating your address information in West Virginia. It is used when you relocate or change your residency within the state.
This Form is used for combining accrued sick and annual leave in West Virginia.
This form is used for making changes to the designated beneficiary in West Virginia.
This form is used for providers to request more information about the Comprehensive Care Partnership (CCP) Program in West Virginia.
This form is used for prepayment of maternity benefits in the state of West Virginia.
This Form is used for enrolling in the Premium Conversion Plan in West Virginia. It allows employees to pay for certain insurance premiums with pre-tax dollars.
This form is used for reporting suspected insurance fraud by citizens in West Virginia.
This Form is used for providing a summary of personal pay information for active employees in West Virginia.
This Form is used for reporting changes in the demographic information of retirees in West Virginia.
This form is used for the Peia Weight Management Program in West Virginia. It is a medical drop/release form that may be required for participation in the program.
This form is used for reviewing group life insurance policies with Metlife in West Virginia.
This form is used for requesting reimbursement of medical travel expenses in West Virginia.
