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, King, Kittitas, Okanogan, Pierce, Walla Walla, Whitman, and Yakima Counties
- Apple Health Integrated Managed Care - English (PDF)
- Apple Health Integrated Managed Care - Spanish (PDF)
- Behavioral Health Services Only (BHSO) - English (PDF)
- Behavioral Health Services Only (BHSO) - Spanish (PDF)
Handbooks for Members in Clallam, Cowlitz, Grays Harbor, Island, Jefferson, Kitsap, Lewis, Mason, Pacific, San Juan, Skagit, Snohomish, Thurston, Wahkiakum, and Whatcom Counties
- Appeal Form for Member Authorized Representative (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)
- 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