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Iowa

Member Submitted Claim Form

Appeal Form PDF File
See also How to Appeal

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)

Individual Health Plan Contract Change Form PDF File

Access all your benefit information, forms, wellness & rewards and more through your Medicare Advantage member portal.

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 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.

South Dakota

Access all your benefit information, forms, wellness & rewards and more through your Medicare Advantage member portal.

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 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 Information PDF 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.

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