Below are the forms most commonly needed by Boeing members. If you do not find the form you are looking for in this section, please contact Boeing Customer Service at 1 (800) 422-7713.
Note: To view, save, or print a copy of the forms, you will require Adobe® Acrobat® Reader. If you do not have Acrobat® Reader, you can download a free copy from Adobe®.
Medical Claim Form (PDF)
This form is used for all member submitted medical claims. Complete this form if services are received from a provider who does not bill the plan directly.
Member submitted medical claims within the Regence service area send form to:
Boeing Plan Claims
PO Box 21065
Seattle, WA 98111-3065
Fax: 1 (877) 357-3418
Medicare-eligible
Provider will bill Medicare directly for services. After Medicare has completed processing your claim, have your provider submit your claim to the local Blue Cross Blue Shield plan where services were rendered. Contact Boeing Customer Service to obtain the address of the local plan.
All other Boeing Plans and locations
Submit claims to the local Blue Cross Blue Shield plan where services were rendered. Contact Boeing Customer Service to obtain the address of the local plan.
Prescription Claim Form (PDF)
This form is used for Selections®, Select Network Plan, and Selections Plus plans only. Complete this form in circumstances such as a pharmacy submission issue during purchase, if a member is new to a plan and does not have a pharmacy card, eligibility issues, and/or an authorization was received but not loaded into the pharmacy's system prior to purchase.
Send form to:
Boeing Plan Claims
PO Box 21065
Seattle, WA 98111-3065
Fax: 1 (877) 357-3418
For all other Boeing Plans, prescription medications are covered through a prescription program managed by Medco. Contact Medco at 1 (800) 841-2797.
Vision Claim Form (PDF)
This form is used for Selections, Select Network and Selections Plus plans only. Complete this form if vision care is received from a provider who does not bill the plan directly.
Send form to:
Boeing Plan Claims
PO Box 21065
Seattle, WA 98111-3065
Fax: 1 (877) 357-3418
For all other Boeing Plans, routine vision care services are covered through Vision Service Plan (VSP). Contact VSP at 1 (800) 877-7195.
Medical Service Inquiry Form (PDF)
Complete this form to give authorization for Regence to pay your claims and recover once there is a settlement for services related to the following: injuries or illnesses caused by a third party such as motor vehicle accidents, work-related injuries and illnesses, injuries on another person's property (such as falling in a grocery store), defective products or machinery, and food poisoning.
Send form to:
Boeing Plan Correspondence
PO Box 21065
Seattle, WA 98111-3065
Fax: 1 (877) 357-3419
Multiple Coverage Inquiry Form (PDF)
Complete this form if you and your dependents have any other insurance as Regence is required to coordinate payment of benefits.
Send form to:
Boeing Plan Correspondence
PO Box 21065
Seattle, WA 98111-3065
Fax: 1 (877) 357-3419
Authorization to Disclose Protected Health Information Form (PDF)
Use this form to authorize Regence to disclose health information to a designated party for a specfic purpose.
Send form to:
Boeing Plan Correspondence
PO Box 91015
Mail Stop BU248
Seattle, WA 98111-9115
Fax: 1 (877) 663-7526
Dependent Child Out-of-Area Notification Form (PDF)
This form is used for the Select NetworkSM Plan only. Completion of this form ensures claims will be processed accurately for dependent children residing outside the Regence service area.
Send form to:
Boeing Plan Correspondence
PO Box 21065
Seattle, WA 98111-3065
Fax: 1 (877) 357-3419
Health Insurance Claim (HIC) Number Form (PDF)
This form is used for the Traditional and Basic Indemnity Plans only. Complete this form if you are Medicare-eligible as Regence is required to coordinate payment of benefits.
Send form to:
Boeing Plan Correspondence
PO Box 21065
Seattle, WA 98111-3065
Fax: 1 (877) 357-3419
Coordination of Care Form (PDF)
This form is used for the Selections® Plus plan only. Completion of this form authorizes Regence to contact your physician to coordinate your care, especially for those with ongoing or complicated medical conditions.
Send form to:
Boeing Plan Correspondence
PO Box 21065
Seattle, WA 98111-3065
Fax: 1 (877) 357-3419
Boeing Member Appeals Process (PDF)
This document outlines the appeal rights available to Boeing members for services denied for coverage of payment.
Send appeals to:
Boeing Plan Appeals and Correspondence
PO Box 91015
Mail Stop BU248
Seattle, WA 98111-9115
Fax: 1 (877) 663-7526
E-mail: boeing@regence.com