Member Handbooks and Forms
To view more details on covered benefits, visit the Benefits and Services section. Select the Benefits Overview that is relevant to you for a summary and a more detailed, printable list.
Handbooks for Members in Asotin, Benton, Chelan, Columbia, Douglas, Franklin, Garfield, Grant, Island, King, Kittitas, Okanogan, Pierce, San Juan, Snohomish, Walla Walla, Whatcom, Whitman, and Yakima Countiesm
- Apple Health Integrated Managed Care - English (PDF)
- Apple Health Integrated Managed Care - Spanish (PDF)
Behavioral Health Services Only
- Appeal Form for Member Authorized Representative (PDF)
- Appeal Request form (PDF)
- Primary Care Physician (PCP) Change Form - English (PDF)
- Primary Care Physician (PCP) Change Form - Spanish (PDF)
- Authorization to Disclose Personal Health Information - English (PDF)
- Authorization to Disclose Personal Health Information - Spanish (PDF)
- Notification of Pregnancy (NOP) form (members) - English (PDF) | Spanish NOP (PDF)
- Revocation of Authorization to Disclose Health Information - English (PDF)
- Revocation of Authorization to Disclose Health Information - Spanish (PDF)
- Member Grievance Form (PDF)
- DME Referral Form
- Prescription Claim Reimbursement Form (PDF)
Health Home is a set of services to assist members with chronic conditions, like diabetes, asthma, heart disease and others. Our care coordinators help you create a plan to improve and support your care. For more information, check out the links below.
- Adult Immunization Record (PDF)
- Advance Directives One-sheet - English and Spanish (PDF)
- Tobacco Cessation Program Description
- Medically Intensive Children's Program (MICP) flyer - English (PDF)
- Medically Intensive Children's Program (MICP) flyer - Spanish (PDF)
- Preventive Health and Clinical Practice Guidelines