Forms

Claims 

Insured through:

Wellmark BCBS of Iowa

Wellmark Health Plan of Iowa

Insured through:

Wellmark BCBS of South Dakota

Choose the form based on the state you're insured through, regardless of where services were received. The back of your ID card states if you are insured through Wellmark BCBS of Iowa, Wellmark Health Plan of Iowa, or Wellmark BCBS of South Dakota.

Member Claim Form #C-5321 – Iowa  pdf image  

Member Claim Form #C-3344 – 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  

Transplant Travel & Lodging Reimbursement Form with Food #C-3625 - South Dakota  pdf image  
Transplant Travel & Lodging Reimbursement Form with Food #C-4603 - Iowa  pdf image

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

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

 

Hy-Vee Travel and Lodging Reimbursement #C-4618259  pdf image

 

Unity Point Travel and Lodging Reimbursement #C-4633  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)

Iowa South Dakota

Application for Individual Health & Dental Insurance #N-53290 (11/15) - Iowa  pdf image  

Application for Individual Health Insurance #N-33136 (11/15) - South Dakota  pdf image  

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

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

 

Individual Health Plan Contract Change Form #N-5428 12/14 – Iowa  pdf image

 

Individual Health Plan Contract Change Form for ACA plans #N-5432 11/15 – Iowa  pdf image

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

 

Individual Health Plan Contract Change Form for ACA plans #N-3706 11/15 – South Dakota  pdf image

Personal Doctor Selection Form #N-5423 10/15  pdf image

 

Tobacco Declaration Form #M-57190 (use for Affordable Care Act (ACA) plans) – Iowa  pdf image

 

Tobacco Declaration Form #M-5749 (use for grandfathered and pre-ACA non-grandfathered plans) – Iowa  pdf image

 

Medicare Supplement

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

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

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

Pharmacy

Mail Order for All Members
Mail Order Pharmacy Registration and Prescription Order Form #P-23313  pdf image

Mail Order Pharmacy Prescription Fax Form #P-23314  pdf image  

All Members (Use for claims after 1/1/16)
Prescription Reimbursement Claim Form #P-4303  pdf image  
All Members (Use for claims prior to 12/31/15)

Prescription Reimbursement Claim Form Comprehensive Major Medical (CMM) Form - Iowa #P-3319 pdf image

Prescription Reimbursement Claim Form Comprehensive Major Medical (CMM) Form - South Dakota #P-5344  pdf image

Prescription Reimbursement Claim Form Drug Card - South Dakota #P-3320 pdf image

Prescription Reimbursement Claim Form Drug Card - Iowa #P-4303 pdf image

Formulary Exception
Exception Request for Non-Formulary Prescription Drugs #P-23282  pdf image  
Other
Hawk-I Prescription Reimbursement Claim Form #P-4318260  pdf image

 

Miscellaneous

 

 All Members

Agent of Record Form – Individual IA & SD  pdf image

Agent of Record Form – Group IA & SD  pdf image

Reporting Health Care Fraud & Abuse

Iowa South 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 release 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  

Tyson Personal Representative Appointment and Authorization to Release Protected Health Information 

 


© Wellmark, Inc. All Rights Reserved.
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 | Browser Information