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Forms

There are several forms that you can either download and print online, or order paper copies to be sent to you by mail using our UMP Publication Order Form.

Medical and Vision Claim Forms

UMP Medical Claim form (150K)
UMP Vision Hardware Claim form (105K) Use this form for eyeglasses & contacts

Prescription Drug Forms

Mail-Order Form (2008)

2008 Mail-Order Prescription Order Form (509K)

Paper Claims

WA State Rx Services Prescription Drug Claim Form (123K)
Note: Express Scripts will not process 2007 claims after April 1

See also: Instructions for submitting a prescription drug claim form

Other Forms