Download Forms

To open and print the following PDF forms you’ll need Adobe® Acrobat® Reader. You may also request forms by calling Member Services at the number listed on the back of your member card.

• Prescription Medication Mail Order Forms
• Prescription Medication Claim Forms
• Authorization for Use and Disclosure of Protected Health Information

Prescription Medication Mail Order Forms

You can use the forms listed below (in PDF format) to order your prescriptions.

Postal Prescription Services (PPS) Registration & Prescription Order Form

Prescription Medication Claim Forms

You can use the following claim form if you:

• Forgot to present your member card to the pharmacist when you purchased your medication and you need reimbursement.
• Need to submit for reimbursement subject to the coverage provisions of your plan.

Simply attach your original prescription receipts to your completed form and mail to the address indicated. You may want to make copies of your original receipts as we’re unable to return them to you.

• Prescription Medication Claim Form - Regence BlueShield of Idaho
• Prescription Medication Claim Form - Regence BlueCross BlueShield of Oregon
• Prescription Medication Claim Form - Regence BlueCross BlueShield of Utah
• Prescription Medication Claim Form - Regence BlueShield (in much of the state of Washington)
• Prescription Medication Claim Form - Asuris Northwest Health

Authorization for Use and Disclosure of Protected Health Information

Authorization for a member's health care providers to disclose health information to a designated party for a specific purpose.

• Authorization to Disclose Protected Health Information - Regence BlueShield of Idaho
• Authorization to Disclose Protected Health Information - Regence BlueCross BlueShield of Oregon
• Authorization to Disclose Protected Health Information - Regence BlueCross BlueShield of Utah
• Authorization to Disclose Protected Health Information - Regence BlueShield (in much of the state of Washington)
• Authorization to Disclose Protected Health Information - Asuris Northwest Health