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 (FSA) and Health Savings Account (HSA) Forms

For questions or if another form is needed, please contact Elizabeth Slack.

• Flexible Spending Eligible Expenses

• Administrative Services Agreement

• FSA Employee Application

• Flex Reimbursement Request

• Letter of Medical Necessity

• Flexible Spending Account Employer Set-up Request

• Premium-Only Plan Employer Set-up Request

• HSA Administrative Enrollment Form

• HSA Transfer Form

• HSA Employer Group Enrollment Application