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Forms

Claims

 

IowaSouth Dakota
Member Claim Form #C-5321 – Iowa pdf image  Member Claim Form #C-3344 – South Dakota pdf image 
Drug Card Prescription Claim Form (Blue RxSM or Blue Rx PreferredSM) #P-4303 – Iowa pdf image  Drug Card Prescription Claim Form (Blue Rx or Blue Rx Preferred) #P-3320 – South Dakota pdf image 
CMM Prescription Claim Form (drugs covered under health) #P-5344 – Iowa pdf image 

CMM Prescription Claim Form (drugs covered under health) #P-3319 – South Dakota pdf image 

Transplant Travel & Lodging Reimbursement Form with Food #C-4603 - Iowa pdf image 

Transplant Travel & Lodging Reimbursement Form with Food #C-3625 - South Dakota pdf image 

Transplant Travel & LodgingReimbursement Form without Food #C-4604 - Iowa pdf image 

Transplant Travel & LodgingReimbursement Form without Food #C-3626 - South Dakota pdf image 

PPO/CMM Vision Claim Form #C-53175 – Iowa pdf image  Vision Claim Form #C-3352 – South Dakota pdf image 

WHPI Vision Claim Form #C-9331 – Iowa pdf image 

 
Blue DentalSM Claim Form #C-0365 – Iowa pdf image 

 

University of Iowa Members - Transplant Lodging Reimbursement Form pdf image    

 
BlueCard Worldwide® International Claim Form

BlueCard Worldwide International Claim Form:

Individual Health Plans (Coverage that Isn't Through an Employer)

IowaSouth Dakota

Application for Individual Health & Dental  Insurance #N-53290 - Iowa pdf image   

Application for Individual Health & Dental  Insurance #N-33136 - South Dakota pdf image

Authorization for Automatic Account Withdrawal #M-5779 – Iowa pdf image 

Authorization for Automatic Account Withdrawal #M-3506 – South Dakota pdf image

 

Attestation of No Medicare Part A and Part B #N-53301 - Iowa pdf image

Attestation of No Medicare Part A and Part B #N-33149 - South Dakota pdf image

Individual Health Plan Contract Change Form #N-5428 1/14 – Iowa pdf image

 

Individual Health Plan Contract Change Form for new ACA plans #N-5432 5/14 – Iowa pdf image

Individual Health Plan Contract Change Form #N-3704 – South Dakota pdf image

 

Individual Health Plan Contract Change Form for new ACA plans #N-3706 – South Dakota pdf image

Primary Care Provider (PCP) Selection Form #N-5423 5/12 pdf image

 

Tobacco Declaration Form #M-5749 – Iowa pdf image

 

Medicare Supplement

IowaSouth Dakota
Application for MedicareBlue Supplement #M-53314 8/13 pdf image 

Application for MedicareBlue Supplement #M-3507 – South Dakota 8/13 pdf image 

Acknowledgement of Nonduplication-Medicare Supplement #M-5728 – Iowa 
pdf image 
 
Authorization for Automatic Account Withdrawal #M-5779 – Iowa pdf image   

Pharmacy

All Members
CMM Prescription Claim Form (drugs covered under health) #P-5344 – Iowa pdf image 
Drug Card Prescription Claim Form (Blue RxSM or Blue Rx PreferredSM) #P-4303 – Iowa pdf image 
Formulary Exception (Includes Healthy and Well Kids in Iowa hawk-i)
Formulary Exception Request - #P-23282 pdf image 

Flexible Spending Accounts

Please note: If you have been notified that your employer spending account through Wellmark is being serviced by WageWorks, you can now manage your account and obtain forms through the participant website.

 

All Members
Authorization Forms
Automatic Reimbursement Authorization Form #H-8340 pdf image 

Direct Deposit Authorization Form #G-8704 pdf image

Individual Authorizing Disclosure - Iowa pdf image 

Individual Authorizing Disclosure - South Dakota pdf image 

Reimbursement Forms

2013 Medical Travel Expense Report pdf image 

2012 Medical Travel Expense Form #H-83109 pdf image 

Flexible Benefits Request for Reimbursement #H-8303 pdf image
Flexible Benefits Request for Reimbursement (Spanish) #H-8371 pdf image
Flexible Benefits Plan Medical Reimbursement Accounts Cotinuation Election Form #H-8373 pdf image 
Medical Necessity Form #H-8401 pdf image 
Orthodontic Payment Form #H-8402 pdf image 

Miscellaneous

 

 All Members
IowaSouth Dakota
Appeal Form #C-53158 (English) – Iowa pdf image 
Appeal Form #C-53158 (Spanish) – Iowa pdf image 

See also How to Appeal - Iowa pdf image 

Appeal Form #C-3347 – South Dakota pdf image 
See also How to Appeal - South Dakota pdf image 

 

File an External Review – South Dakota Division of Insurance leave site image

Authorization for Disclosure to Housing Authority #T-4601 – Iowa pdf image 
This form is used to authorize Wellmark to disclose premium information to a housing authority at the request of the individual.
Authorization for Disclosure to Housing Authority #T-3609 – South Dakota pdf image 
This form is used to authorize Wellmark to disclose premium information to a housing authority at the request of the individual.

Authorization to Use or Disclose Protected Health Information #T-5605 – Iowapdf image 
This form is used to authorize Wellmark to release protected health information to an individual or entity other than yourself. See also Instructions for #T-5605 pdf image .

Authorization to Use or Disclose Protected Health Information #T-3601 – South Dakota pdf image 
This form is used to authorize Wellmark to release protected health information to an individual or entity other than yourself. See also Instructions for #T-3601 pdf image .

Personal Representative Appointment and Authorization to Release Protected Health Information #C-5674 – Iowa pdf image
This form is used to appoint someone to act on your behalf, as well as to authorize Wellmark to relase protected health information to them. See also Instructions for #C-5674 pdf image .
Personal Representative Appointment and Authorization to Release Protected Health Information #C-3617 – South Dakota pdf image 
This form is used to appoint someone to act on your behalf, as well as to authorize Wellmark to release protected health information to them. See also Instructions for #C-3617 pdf image .
Workers Compensation Questionnaire #C-5518 – Iowa pdf image Workers Compensation Questionnaire #C-3509 – South Dakota pdf image 
Blue Dental PPOSM Enhanced Dental Benefit Enrollment Form #C-0366 pdf image   

Tyson Personal Representative Appointment and Authorization to Release Protected Health Information 

 


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