Forms for Iowa
Insured through:
Wellmark Blue Cross Blue Shield of Iowa
Wellmark Health Plan of Iowa
Member Submitted Claim Form
Blue Cross Blue Shield Global® Claim Form:
Blue Dental℠ Out-Of-Network Claim Form PDF File
Blue Dental℠ Extra Dental Cleaning Enrollment Form PDF File — If your plan offers a 3rd annual cleaning and you are pregnant or have diabetes, you can use this form to apply. Please refer to your coverage manual Opens in new window for details.
Blue Dental℠ Extra Dental Benefits Enrollment Form PDF File — If your plan offers additional dental benefits to members with specific medical conditions, you can use this form to enroll. Please refer to your coverage manual Opens in new window for details.
Authorization for Automatic Account Withdrawal Form:
- Exchange PDF File (If you bought your plan on Healthcare.gov or through your state's exchange)
- Non-Exchange PDF File (If you did not buy your plan on Healthcare.gov or through your state's exchange)
Reporting Health Care Fraud & Abuse
Agent/Agency of Record Transfer Request PDF File
Appeal Form PDF File
See also How to Appeal
Authorization for Disclosure to Housing Authority PDF File
This form is used to authorize Wellmark to disclosure premium information to a housing authority at the request of the individual.
Authorization to Use or Disclose Protected Health Information PDF File
This form is used to authorize Wellmark to release protected health information to an individual or entity other than yourself.
Consent for Care Management and Care Coordination PDF File
This form is used to authorize your provider to disclose protected health information related to substance use disorder to Wellmark.
Personal Representative Appointment and Authorization to Release Protected Health InformationPDF File
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.
