State Agency Directory | Online Services
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Find a Form or Document

The following is an alphabetical list of forms and documents on the Web site.

If you see (Complete Online) next to a form, you can do this online by going to Manage My Benefits. It's easier, faster and leads to fewer mistakes than printing a form and sending it to PEIA.

 ***If you have previously had PEIA as your insurance carrier, you are unable to use Manage My Benefits to log in and enroll. 
Please see your HR department to fill out paper enrollment forms.


ABA Services Preauthor​ization ​Form

Annual Routine Physical and Screening Examination Form

Authorization to Release/Disc​lose Form

Authorization to Remove Coordi​nator Form

Basic and/or Optional Life Insurance Change of Beneficiary 

Basic Life ​​ (Complete Online)

Change-in-Address Form (Complete Online)

Change-in-Status Form  (Compl​ete Online) 
        Please note, to update your Mountaineer Flexible Benefits elections after a change-in-status event, you must complete an Enrollment Form with FBMC.                    ​Employees must submit the form, as well as supporting documentation, to their Agency Benefit Coordinator within the month of or two months                                    following the status-changing event. Please visit​ to download the appropriate          ​Enrollment form.

Combined Leave Form

Comprehensive Care Program Enrollment Form

Coordination of Benefits (Form no longer required, call UMR at 1-888-440-7342 to update information)

Dependent Documentation Memo​

Direct Draft Form

Disabled Dependent Eligibility Applica​tion

Electronic Funds Transfer Form

Health Benefits Enrollment Fo​rm  (Complete Online)

HealthCheck Forms

Maternity Benefit Pre-Pay​ment Form

Medical Claim Form 

Medical Travel Expense Reimbursement Request Form

Mountaineer Flexible Benefits Enrollment Form (Active Employees)

Mountaineer F​lexible Benefits Enrollment Form (Retirees)

Mountaineer Flexible Benefits Change Form (A​ctive Employees)

Mountaineer Flexible Benefits Change Form (Retirees)

Mountaineer Flexible Benefits Dental and Vision Claim Forms

​Notice of Death Form (Please contact MetLife at 888-466-8640)

Optional Life Insurance and Dependent Life Insurance Enrollment Form [Complete Online]

Out-of-Area Dependent Benefit Form (Must be updated annually)

Patient Audit Form

Premium and Benefit Assistance Form (Medicare) PY2025

Premium and Benefit Assistance Form (Medicare) PY2024

Premium and Benefit Assistance Form (Non-Medicare) PY2025​​

Premium and Benefit Assistance Form (Non-Medicar​e) PY2024​​

Premium Waiver - Life Insurance Disability

​​​Prescription Drug Claim ​Form

Provider Contracted Appeals Agent/Advocate form

Provider Demograp​hic W​orksheet 

Provider Request for More Information Form

Request for Prior Approval of Services Form

Retired Employee's Optional and Dependent Life Insurance Enrollment Form

Retirement Health Benefits and Basic Life Enrollment Form

Surviving Dependents Health Benefits Enrollment Form​​​

Transition of Care Form

Termination Form [Complete Online]


ACA Reporting
Benefit Coordinators Reference Manual
Directions to PEIA
Face to Face Diabetes Management Brochure
Life Insurance Information
Manage My Benefits Enrollment Instructions
Medicare Advantage Plan Booklets
Medicare Advantage Drug Formulary
Medicare Shopper's Guides
Mountaineer Flexible Benefits Plan (Active Employees)
Mountaineer Flexible Benefits Plan (Retirees) 
Nicotine Replacement Therapies
Notice of Privacy Practices
OPEB Plan Participation Standards
Premium Conversion Plan Information
Provider Directory
River Valley Health Alliance Termination Letter
Shopper’s Guides
Special Medicare Plan Booklets
Summary Plan Descriptions

Other Information

Fee Schedules & Manuals
Financial Reports
Wellness Tools
Health Tips
Historic Fee Schedules
Premium Rates
Requests for Proposals / Requests for Quotations
Member N​ewsletters