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Forms

Applications & Change Forms

Note: For non-English forms, please refer to HyVeeNet

Blue Access/PPO Locations Enrollment Form ( 83KB)
PPO Locations Only Enrollment Form ( 83KB)

Claim Forms

Health Patient Claim Form C-5321 ( 122KB)

Flexible Benefit Forms

Flexible Benefits Enrollment Form H-8759 ( 170KB)

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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.

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