| Iowa |
South Dakota |
Appeal Form #C-53158 – Iowa  (59KB)
See also How to Appeal - Iowa (19KB) |
Appeal Form #C-3347 – South Dakota (145KB)
See also How to Appeal - South Dakota (20KB) |
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Authorization to Use or Disclose Protected Health Information #T-5605 – Iowa (262KB)
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 (7KB).
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Authorization to Use or Disclose Protected Health Information #T-3601 – South Dakota (34KB)
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 (7KB).
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Personal Representative Appointment and Authorization to Release Protected Health Information #C-5674 – Iowa (40KB)
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 (8KB).
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Personal Representative Appointment and Authorization to Release Protected Health Information #C-3617 – South Dakota (36KB)
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 (8KB).
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Authorization for Disclosure to Housing Authority #T-4601 – Iowa (221KB)
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 for Disclosure to Housing Authority #T-3609 – South Dakota (215KB)
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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| Workers Compensation/Subrogation Combination Questionnaire #C-5347 – Iowa (40KB) |
Workers Compensation/Subrogation Combination Questionnaire #C-3509 – South Dakota (110KB) |
