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| Iowa |
South Dakota |
Appeal Form #C-53158 – Iowa 
See also How to Appeal - Iowa |
Appeal Form #C-3347 – South Dakota
See also How to Appeal - South Dakota
File an External Review – South Dakota Division of Insurance 
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Authorization for Disclosure to Housing Authority #T-4601 – Iowa
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
This form is used to authorize Wellmark to disclose premium information to a housing authority at the request of the individual. |
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Authorization to Use or Disclose Protected Health Information #T-5605 – Iowa
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 .
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Authorization to Use or Disclose Protected Health Information #T-3601 – South Dakota
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 .
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Personal Representative Appointment and Authorization to Release Protected Health Information #C-5674 – Iowa
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 .
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Personal Representative Appointment and Authorization to Release Protected Health Information #C-3617 – South Dakota
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 .
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| Workers Compensation Questionnaire #C-5518 – Iowa |
Workers Compensation Questionnaire #C-3509 – South Dakota |
| Blue Dental PPOSM Enhanced Dental Benefit Enrollment Form #C-0366 |
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Tyson Personal Representative Appointment and Authorization to Release Protected Health Information
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