Iowa Member Forms

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• Claim Forms
• Health Savings Account (HSA) Forms
• Individual Health Plans
• Medicare Supplement (Over 65)

Claim Forms:

• BlueCard Worldwide International Claim Form - #N20-02-246
  • English Version
  • Spanish Version
• BlueDental Claim Form #C-0365
• Flexible Benefits Forms
• Member Claim Form #C-5321
• Vision Claim Form #C-53175
• Drug Card Members (Blue Rx or Blue Rx Preferred) - #P-4303
• CMM Member (drugs covered under health) - #P-5344

Medication Adherence Card

• Download the Medication Adherence Card to keep track of your family’s medications.

Prescription Mail Order Form

• Mail Order Form (including Blue Plus Club) - #P-5336
  

Miscellaneous Forms

• Appeal Form #C-53158
• Authorization to Use or Disclose Protected Health Information #T-5605
  This form is used to authorize Wellmark to release protected health information to an individual or entity other than yourself.
• Authorized Representative Appointment and Authorization for Release of Information #C-5674(U)
  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.
• Prior Approval Matrix
• Workers Compensation/Subrogation Combination Questionnaire  

Health Savings Account (HSA) Forms:

• First Horizon Msaver HSA Application #M-53789
• First Horizon Msaver Request for Transfer to an HSA #M-53790
• First Horizon Msaver HSA Rollover Review #M-53791

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

Short Term Major Medical

• Application for Short-Term Major Medical Policy #M-5733

Direct Pay

• Application for Individual Health, Dental & Life Insurance(M-53254, Pool 5)
• Application for Individual Health, Dental & Life Insurance (M-5437, Pool 4)
• Application for Individual Health & Life Insurance (M-5434, Pool 3)
• Application for Individual Health and Life Insurance (M-5416, Pools 1 & 2)
• Authorization for Automatic Account Withdrawal #M-5779
• Rider Removal Request #P-5342
• Tobacco Declaration Form #M-5749
• Blue Transitions – Application for Alliance Select Transitions Coverage #N-5427
• Authorization for Automatic Account Withdrawal (#M-5750, for use with Blue Transitions)

State Mandated Coverage

• Application for Blue Care, Secure Blue, and Secure Blue Select #M-5768
• Supplemental Application for Blue Care, Secure Blue, and Secure Blue Select #M-5769

Medicare Supplement (Over 65):

• Acknowledgement of Nonduplication-Medicare Supplement #M-5728
• Notice to Applicant Regarding Replacement of Medicare Supplement Insurance #M-53106
• Authorization for Automatic Account Withdrawal #M-5779
• Application for Senior Blue Medicare Supplement Health Insurance Plan #M-53314(U)

Copyright© 2008 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. Blue Cross®, Blue Shield®, and the Cross® and Shield® symbols are registered marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.