Member Submitted Claim Form
Medical appeal form
See also how to appeal a medical claim
Personal Representative Appointment and Authorization to Release Protected Health Information
Appoint an individual, such as a caregiver or provider, to submit claims on your behalf.
Authorization criteria request form
Blue DentalSM Claim Form:
Blue Cross Blue Shield Global® Claim Form:
Iowa individual health plans
Coverage not through an employer
Authorization for Automatic Account Withdrawal Form:
- Exchange (If you bought your plan on Healthcare.gov or through your state's exchange)
- Non-Exchange (If you did not buy your plan on Healthcare.gov or through your state's exchange)
Individual Health Plan Contract Change Form
Personal Representative Appointment and Authorization to Release Protected Health Information
Appoint an individual, such as a caregiver or provider, to submit claims or appeals on your behalf.
Manage data-sharing elections (interoperability) — If you’re enrolled in a Qualified Health Plan (QHP), as defined by the Affordable Care Act (ACA), you can choose to exchange your health data with apps, providers and other insurers.
Interoperability personal representatives — An interoperability personal representative can make decisions about a member’s data sharing preferences on their behalf.
Reporting Health Care Fraud & Abuse
Agent/Agency of Record Transfer Request
Authorization for Disclosure to Housing Authority
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
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
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
Authorize Wellmark to disclose protected health information to a representative at your request.
Notice of Protection Provided by Iowa Life and Health Guaranty Association
Member Submitted Claim Form
Medical appeal form
See also how to appeal a medical claim
Personal Representative Appointment and Authorization to Release Protected Health Information
Appoint an individual, such as a caregiver or provider to submit claims on your behalf.
Authorization criteria request form
Blue Cross Blue Shield Global® Core Claim Form:
South Dakota individual health plans
Coverage not through an employer
Authorization for Automatic Account Withdrawal form:
- Exchange (If you bought your plan on Healthcare.gov or through your state's exchange)
- Non-Exchange (If you did not buy your plan on Healthcare.gov or through your state's exchange)
Individual Health Plan Contract Change Form
Personal Representative Appointment and Authorization to Release Protected Health Information
Appoint an individual, such as a caregiver or provider, to submit claims or appeals on your behalf.
Manage data-sharing elections (interoperability) — If you’re enrolled in a Qualified Health Plan (QHP), as defined by the Affordable Care Act (ACA), you can choose to exchange your health data with apps, providers and other insurers.
Interoperability personal representatives — An interoperability personal representative can make decisions about a member’s data sharing preferences on their behalf.
Reporting Health Care Fraud & Abuse
Agent/Agency of Record Transfer Request
File an External Review - South Dakota Division of Insurance
Authorization for Disclosure to Housing Authority
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
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
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
Authorize Wellmark to disclose protected health information to a representative at your request.
Disclaimers
Avesis Vision is an independent vision insurance company that does not provide Wellmark Blue Cross and Blue Shield products and services. Avesis Vision is underwritten by Fidelity Security Life Insurance.