Select from the following forms to print, complete, and mail back to us.

If you do not see the form that you need or have questions about any of these forms, please contact Customer Service, 8:00 a.m. to 8:00 p.m., 7 days a week, at 1-800-942-0247 (TTY Relay: Dial 7-1-1). You will need Adobe Acrobat Reader to view the PDF documents on this website. Download Adobe Acrobat Reader for free. 

2019 Plan Forms

 

Other Forms

Appointing a Representative

An appointed representative is a relative, friend, advocate, doctor, or another person who is authorized to act on your behalf in obtaining a grievance, coverage determination or appeal. If you would like to appoint a representative, both you and your representative must complete the form below and mail it to Community Health Plan of Washington.

Appointment of Representative  |  Nombramiento de un Representante  |  Appointment of Representative (Large Print)

Completed forms can be mailed to:

Community Health Plan of Washington
ATTN: Community HealthFirst
1111 Third Avenue, Suite 400
Seattle, WA  98101

Prescription Drug Forms    |    Health Information Disclosure Forms    |     Privacy Forms