Spending Account Forms
COBRA Continuation Election for Medical Reimbursement Accounts #H-8373
Health Reimbursement Account (HRA) Employer Application #H-8383
Health Savings Account (HSA) Employer Application #H-83117
Premium Only Plan Application #M-53216
Flexible Spending Account (FSA) Employer Application #H-8381
Please contact the
Wellmark Ancillary Support Team
to obtain the appropriate enrollment form for your plan.
Administrative Forms for Employees
View and download
employee flex forms
Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota.
Privacy & Legal