The following is an alphabetical list of forms and documents. 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. Please note, to update your Mountaineer Flexible Benefits elections after a change-in-status event, you must complete an Enrollment Form with Mountaineer Flexible Benefits/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.
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.
Forms
- ABA Services Pre-Authorization 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 - Please visit MetLife's website to update
- Basic Life (Complete Online)
- Change-in-Address Form (Complete Online)
- Change-in-Status Form (Complete Online)
- 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 Eligibility Documentation Memo
- Direct Draft Form
- Disabled Dependent Eligibility Application
- Electronic Funds Transfer Form
- Health Care Fraud and Abuse Form
- Health Benefits Enrollment Form (Complete Online)
- HealthCheck Forms
- Maternity Benefit Pre-Payment Form
- Medical Claim Form
- Medical Travel Expense Reimbursement Request Form
- Mountaineer Flexible Benefits Enrollment Form Plan Year 2027 (Active Employees)
- Mountaineer Flexible Benefits Enrollment Form Plan Year 2027 (Retirees)
- Mountaineer Flexible Benefits Change Form (Active 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 to update information.
- Open Enrollment Transfer Form(Complete Online)
- 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 PY2027 (Medicare AND Non-Medicare)
- Premium and Benefit Assistance Form PY2026 (Medicare AND Non-Medicare)
- Premium Waiver - Life Insurance Disability
- Prescription Drug Claim Form
- Provider Contracted Appeals Agent/Advocate 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 Enrollment Form
- Spousal Surcharge Affidavit
- Surviving Dependents Health Benefits Enrollment Form
- Transition of Care Form
- Termination Form (Complete Online)
Documents
- ACA Reporting
- Benefit Coordinators Reference Manual
- Benefit Guides
- Face to Face Diabetes Management Brochure
- Manage My Benefits Enrollment Instructions
- Medicare Advantage Plan Booklets
- Medicare Benefit Guides
- Mountaineer Flexible Benefits Guide Plan Year 2027 (Active Employees)
- Mountaineer Flexible Benefits Guide Plan Year 2027 (Retirees)
- Notice of Privacy Practices
- OPEB Plan Participation Standards
- Premium Conversion Plan Form
- Provider Directory
- Special Medicare Plan Booklets
- Summary Plan Descriptions