Regence group administrators 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with SECTION 1 – EMPLOYEE INFORMATION. Fill in your name, member ID number, and address. Indicate if this is an address change by selecting 'Yes' or 'No'. Provide your phone number and marital status.
3. Continue by entering your date of birth and group name and number. If married, include your spouse's name. For divorced individuals claiming for dependents, answer the custody questions.
4. Move to SECTION 2 – PATIENT INFORMATION. Enter the patient's name and address, select their relationship to you, and provide their date of birth.
5. In SECTION 3 – DESCRIPTION OF CLAIM, describe the illness or injury. Specify if it's work-related and provide details about any accidents.
6. Proceed to SECTION 4 – OTHER GROUP HEALTH INSURANCE. Indicate if you or family members have other insurance coverage and provide necessary details.
7. Complete the form by signing in SECTIONS 5, 6, and 7 for certification, claims benefit assignment, and authorization to release information.

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