DAKOTACARE Forms

Access pre-authorization, appeals and privacy forms from this page. If you are in need of a form and cannot find it here or on the member, agent or provider portal, please contact us:

Phone: 605-334-4000     Toll-Free: 800-325-5598     E-mail Customer Service at customer-service@dakotacare.com

DAKOTACARE ONE Individual/Family Forms  l   Employee Applications  l  DAKOTACARE Group Forms  l   DAS Forms  l   Flex Forms  


Individual/Family DAKOTACAREONE Forms

Billing Change Form 

Used to change the account in which your premiums are drafted from.


Mail Order Service Form 

Used to receive prescriptions via mail. 


Add/Change/Termination Form 

Used to make an addition, change, or termination on a DAKOTACAREONE policy.


Authorization for Disclosure of Health Information 

Used to grant access for DAKOTACARE to discuss your policy with others of your selection.


Employee Applications 

Employee Application – Transitional Extension Groups 

For Groups without an ACA Compliant Plan.


Employee Application – Small Group 

(Groups with 50 or fewer employees)


Employee Application – Large Group 

(Groups with 51 or more employees)


DAKOTACARE Group Forms

ACH Setup/Change Form

Employer Use Only.  Used for groups to change their Billing Account Information.

 Download 

 


Student Verification Form

Used to verify student status for dependents.


Mail Order Service Form

Used to receive prescriptions via mail. 


Add/Change/Termination Form 

Used to make changes or additions to an employee’s coverage. Also used to terminate an employee’s coverage.


Authorization for Disclosure of Health Information 

Used to allow access for DAKOTACARE to discuss your policy with others of your selection.


Flu Shot Claim Form

 Used to request reimbursement for a Flu Shot.


Accident Questionnaire 

Used following an accident.

 
 

DAS Forms

Student Verification Form

Used to verify student status for dependents. 


Accident Questionnaire

Used following an accident.


Authorization for Disclosure of Health Information

Used to allow access for DAKOTACARE to discuss your policy with others of your selection.


Add/Change/Termination Form

Used to make changes or additions to an employee’s coverage. Also used to terminate an employee’s coverage.


Flex Forms

Flex Claim Form

Claim form for medical expense and dependent care reimbursement.


Flex Direct Deposit Reimbursement Form 

Used to have your disbursements deposited directly into your bank account.


Flex Letter of Medical Necessity Form 

Used to verify some potentially qualifying medical expenses.


Flex Change in Status/Termination Form

Employer Only form used to verify changes and terminations


Flex Orthodontics Claim Reimbursement Form 

Used to be reimbursed for Orthodontic services.