 |
|
 |
Farm Bureau Forms
 To view these documents you will need Adobe Reader.
Choose the icon to download for free.
Blue Dental Request Forms:
Educational Brochures:
Group Forms:
Applications
Due to the Health Insurance Portability and Accountability Act (HIPAA),
groups using the health plan applications in the table below are required
to provide a General Notice of Pre-existing Condition Exclusion (PCE)
to employees at or during enrollment. This notice must disclose the
group's specific exclusion period.
Example 1: Group ABC employs fewer than 50 members in Iowa and requires
0 months for new and special enrollees, 18 months for late enrollees,
and a 6 month look back period. Group ABC would select Application
#N-5401 and General Notice of PCE with 0, 18, and 6 months (M-23168).
Example 2: Group XYZ employs more than 50 members in Iowa and requires
12 months for new and special enrollees, 18 months for late enrollees,
and a 6 month look back period. Group XYZ would select Application
#N-5408 and General Notice of PCE with 12, 18, and 6 months (M-23172).
*Note — Small groups signing up with Wellmark for the first
time (with no prior coverage in the previous 3 months) should use
Application #N-5401 and General Notice of PCE with 6, 18, and 6 months
(M-23169) even though special and late entrants would not apply at
the first enrollment.
Instructions: From the table below, select the correct application
for the group, then select the PCE form needed depending on the timeframe
that best fits the group's needs. In the event a group's elected timeframes
are not shown, use the blank form to print and fill in the appropriate timeframes.
| Enrollment Application |
Pre-existing Condition Exclusion Form |
| Small Group Application
for Health, Dental and Life Insurance #N-5401 (PDF) |
General Notice of PCE with 0, 18, and 6 months #M-23168 (PDF)
General Notice of PCE with 6, 18, and 6 months #M-23169 (PDF)
|
| Large Group Application
for Health Insurance #N-5408 (PDF) |
General Notice of PCE with 0, 18, and 6 months #M-23168 (PDF)
General Notice of PCE with 6, 18, and 6 months #M-23169 (PDF)
General Notice of PCE with 11, 18, and 6 months #M-23170 (PDF)
General Notice of PCE with 12, 12, and 6 months #M-23171 (PDF)
General Notice of PCE with 12, 18, and 6 months #M-23172 (PDF)
General Notice of PCE — blank #M-23173 (PDF)
|
| Large Group Application
for Health and Life Insurance #N-5409 (PDF) |
General Notice of PCE with 0, 18, and 6 months #M-23168 (PDF)
General Notice of PCE with 6, 18, and 6 months #M-23169 (PDF)
General Notice of PCE with 11, 18, and 6 months #M-23170 (PDF)
General Notice of PCE with 12, 12, and 6 months #M-23171 (PDF)
General Notice of PCE with 12, 18, and 6 months #M-23172 (PDF)
General Notice of PCE — blank #M-23173 (PDF)
|
| Large Group Application
for Health and Dental Insurance #N-5410 (PDF) |
General Notice of PCE with 0, 18, and 6 months #M-23168 (PDF)
General Notice of PCE with 6, 18, and 6 months #M-23169 (PDF)
General Notice of PCE with 11, 18, and 6 months #M-23170 (PDF)
General Notice of PCE with 12, 12, and 6 months #M-23171 (PDF)
General Notice of PCE with 12, 18, and 6 months #M-23172 (PDF)
General Notice of PCE — blank #M-23173 (PDF)
|
| Large Group Application
for Health, Dental, and Life Insurance #N-5411 (PDF) |
General Notice of PCE with 0, 18, and 6 months #M-23168 (PDF)
General Notice of PCE with 6, 18, and 6 months #M-23169 (PDF)
General Notice of PCE with 11, 18, and 6 months #M-23170 (PDF)
General Notice of PCE with 12, 12, and 6 months #M-23171 (PDF)
General Notice of PCE with 12, 18, and 6 months #M-23172 (PDF)
General Notice of PCE — blank #M-23173 (PDF)
|
Other Applications
Quote Forms
Miscellaneous Group Forms
Identity Marketing Opportunity Application
Individual and Family Forms:
Claim Forms
Applications
Electronic Submission Cover Page
Miscellaneous Direct Pay Forms - under age 65
Miscellaneous Direct Pay Forms - over age 65
Short Term Major Medical
State Mandated Coverage
Marketing Materials/Outlines of Coverage
|
