South Dakota Member Forms

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• Claim Forms
• Health Savings Account (HSA) Forms
• Individual Health Plans
• Medicare Supplement (Over 65)
• Miscellaneous Forms
• Prescription Mail Order Form

Claim Forms:

• BlueCard Worldwide International Claim Form - #N20-02-246
  • English Version
  • Spanish Version
• Flexible Benefits Forms
• Member Claim Form #C-3344
• Vision Claim Form #C-3352
• Drug Card Members (Blue Rx or Blue Rx Preferred) #P-3320
• CMM Members (drugs covered under health) #P-3319

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

Short Term Major Medical

• Application for Short-Term Major Medical Policy #M-3708(U)

Direct Pay

• Application for Individual Health & Life Insurance #M-3510

State Mandated Coverage

• State Sponsored Risk Pool

Medicare Supplement - Over 65

• Application for Senior Blue Medicare Supplement #M-3507
• Notice to Applicant Regarding Replacement of Medical Supplemental Insurance #M-3503

Miscellaneous Forms

• Appeal/Review Form - #C-3347
• Authorization for Automatic Account Withdrawal #M-3506
• Authorization to Use or Disclose Protected Health Information #T-3601
  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-3617(U)
  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.
• Direct Pay Information Change Request Form #N-3704
• Medication Adherence Card to keep track of your family’s medications, you may download the form, or order a free copy from Wellmark today.
• Prior Approval Matrix
• Rider Removal Request #R-3701
• Workers Compensation/Subrogation Combination Questionnaire #C-3509

Prescription Mail Order Form

• Mail Order Form (including Blue Plus Club) - #P-3315

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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.