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 Preauthorization ​Form
Annual Routine Physical and Screening Examination Form
Authorization to Release/Disclose Form
Authorization to Remove Coordinator Form
Basic and/or Optional Life Insurance Change of Beneficiary Form (Complete Online)
Basic Life Insurance Enrollment Form (Complete Online)
Change-in-Address Form (Complete Online)
Change-in-Status Form (Complete 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)
COVID-19 At Home Test Reimbursement Claim Form
Dependent Documentation Memo
Direct Draft Form
Disabled Dependent Eligibility Applica​tion
Electronic Funds Transfer Form
Health Benefits Enrollment Form (Complete Online)
HealthCheck Forms
Maternity Benefit Pre-Payment Form
Medical Claim Form (UMR - For Claims July 1, 2019 to present)​
Medical Travel Expense Reimbursement Request Form
Mountaineer Flexible Benefits Enrollment Form (Active Employees)
Mountaineer Flexible Benefits Enrollment Form (Retirees)
Notice of Death Form
Optional Life Insurance and Dependent Life Insurance Enrollment Form (Complete Online)
Out-of-Area Dependent Benefit Form
Patient Audit Form
Premium and Benefit Assistance Form (Medicare) PY2023
Premium and Benefit Assistance Form (Medicare) PY2022 (Corrected)
Premium and Benefit Assistance Form (non-Medicare) PY2023
Premium and Benefit Assis​tance Form (non-Medicare) PY2022 (Corrected)
Prescription Drug Claim Form
Provider Demographic Worksheet 
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 Insurance Enrollment Form
Sample CCP Provider Contract
Surviving Dependents Health Benefits Enrollment Form
Transition of Care Form
Termination Form (Complete Online)
Waiver of Premium Forms

ACA Reporting
Beneficiary Financial Counseling Brochure

Benefit Coordinators Reference Manual
Common Specialty Medications
Continuous Interstitial Glucose Monitoring System Criteria
Directions to PEIA
Face to Face Diabetes Management Brochure
Full Formulary Listing
Legal, Financial Grief and Legacy Planning Services 
Life Insurance Benefits Booklet
Maintenance Medications List
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
Preferred Drug List
Premium Conversion Plan Information
Preventative Drug List
CVS Caremark Formulary Exclusions
Provider Directory
Retail Maintenance Network (RMN) of Pharmacies in West Virginia
Retail Maintenance Network (RMN) of Pharmacies Outside of West Virginia

River Valley Health Alliance Termination Letter
Shopper’s Guides
Special Medicare Plan Booklets
Summary Plan Descriptions
Travel  Assistance Brochure
Washington County Provider Network

Other Information
Fee Schedules & Manuals
Financial Reports
Wellness Tools
Health Tips
Historic Fee Schedules
Premium Rates
Requests for Proposals / Requests for Quotations