Blue Priority Flex: Member Forms

To view these documents you will need Adobe Reader. Choose the icon to download for free.

Enrollment Guides

• Premium Only Plan Enrollment Guide (H-8110 12/06)
• Blue Priority Flex Enrollment Guide (H-8129 4/08): Without flex debit card, with enrollment form
• Blue Priority Flex Enrollment Guide (H-8130 4/08): With flex debit card, with enrollment form
• Blue Priority Flex Enrollment Guide (H-8131 4/08): With flex debit card, without enrollment form
• Blue Priority Flex Enrollment Guide (H-8132 4/08): Without flex debit card, without enrollment form

• Pre-Tax Premium Payments Mandatory Enrollment Form (H-8707 11/06)
• Pre-Tax Premium Payments Non-Mandatory (H-8711 11/06)
• Employee Reimbursement Account & Pre-Tax Premium Payment Mandatory Combination (H-8754 8/07)
• Employee Reimbursement Account & Pre-Tax Premium Payment Mandatory with Debit Card Authorization (H-8772 1/08)
• Employee Reimbursement Account & Pre-Tax Premium Payment Non-Mandatory Combination (H-8757 8/07)
• Employee Reimbursement Account & Non-Mandatory Pre-Tax Premium Payment with Debit Card Authorization (H-8774 4/08)
• Pre-Tax Premium Payments and Employee Reimbursement Accounts Change Form (H-8764 1/08)
• Health Reimbursement Account with Debit Card Authorization (H-8382 3/08)

Authorization Forms

• Automatic Reimbursement Authorization Form (H-8340 4/08)
• Direct Deposit Authorization Form (G-8704 11/06)

Reimbursement Forms

• 2007 Medical Travel Expense Form (H-8404 3/07)
• Flexible Benefits Request for Reimbursement (H-8303 06/07)
• Medical Necessity Form (H-8401 11/06)
• To receive recurring monthly orthodontic payments, you will need to print and complete the Orthodontic Payment Form (H-8402 12/06)

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.