Forms

Individual and Family Plan Member Forms

• Add, Change or Terminate – Make an addition or change, or terminate a policy
• Authorization for Disclosure of Health Information – Grant others access to information about your policy
• Billing Change – Change the account where we deduct your premium

Employee Forms

• Application for Large Employer Employee Enrollment– Groups with 51 or more employees
• Application for Small Employer Employee Enrollment – Groups with 50 or fewer employees
• Application for Transitional Extension Employee Enrollment – Groups without an ACA-compliant plan
• Authorization for Disclosure of Health Information – Grant others access to information about their DAKOTACARE policy
• Student Verification – Verify student status for dependents

Employer Forms

• Automatic Bank Deposit Electronic Transfer Setup & Change – For employer use only when groups want to change their billing account information
• Add, Change or Terminate – Make changes or additions to an employee’s coverage or terminate an employee’s coverage

Flexible Spending Account

• Forms