forms
The back of your ID card states whether you are insured through Wellmark BCBS of Iowa, Wellmark Health Plan of Iowa, or Wellmark BCBS of South Dakota. Choose the form based on the state you're insured through, regardless of where services were received.
Iowa
Member Submitted Claim Form
Appeal Form PDF File
See also How to Appeal
Personal Representative Appointment and Authorization PDF File
Appoint an individual, such as a caregiver or provider, to submit claims or appeals on your behalf.
Blue Cross Blue Shield Global® Claim Form:
Blue DentalSM Out-Of-Network Claim Form PDF File
Blue DentalSM 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
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 Case 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 Information PDF File
Authorize Wellmark to disclose protected health information to a representative at your request.
Notice of Protection Provided by Iowa Life and Health Guaranty Association PDF File
South Dakota
Member Submitted Claim Form
Appeal Form PDF File
See also How to Appeal
Personal Representative Appointment and Authorization PDF File
Appoint an individual, such as a caregiver or provider, to submit claims or appeals on your behalf.
Blue Cross Blue Shield Global® Core Claim Form:
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
File an External Review - South Dakota Division of Insurance External Site
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 Case 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 Information PDF File
Authorize Wellmark to disclose protected health information to a representative at your request.
Women's Health and Cancer Rights Act Notice South Dakota PDF File
