Forms & Publications for the Group Health Insurance Plan

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Forms for ALL Members

• Physician's Form for Handicapped Dependent (SFN-58798)
• Application for Dependent Disability (SFN-58856)
• Authorization for Use or Disclosure of Protected Health Information (SFN-58769)
• Health Care Information Release Accounting Form (56768)
• Participant's Authorization to Disclose Protected Health Information (SFN-58770)
• Request to Access Protected Health Information (SFN-58771)
• Participant Request for Confidential Communications (SFN-58772)
• Request for Restrictions On Use and/or Disclosure of Protected Health Information (SFN-58773)

Forms for Active Members

• Health Insurance Application or Change (SFN-60036)
• Notice of Change - Member Data Record (SFN 10766)
• Continuation of Group Insurance Coverage (COBRA) (SFN 14120)

Publications for Active Members

• Certificate of Insurance: PPO/Basic Plan - Grandfathered
  • Summary of Benefits & Coverage
  • Dakota Plan Features
  • Preventive Screening
• Certificate of Insurance: PPO/Basic Plan - Non-Grandfathered
  • Summary of Benefits & Coverage
• Certificate of Insurance: High Deductible Health Plan
  • Summary of Benefits & Coverage
  • HDHP Benefit Schedule
• Guide to Explanation of Benefits
• Is Case Management for You?

Forms for Retirees & Dependents

• Authorization for Premium Deduction (SFN 50134)
• Retiree Group Health Insurance Application (SFN 16277)
• Retiree Health Insurance with Medicare Application (SFN-59562)
• Retiree Continuation of Group Health Insurance Coverage (COBRA) (SFN 53799)
• Continuation of Group Insurance Coverage (COBRA) (SFN 14120)
• Employer Verification of Insurance Coverage (SFN 53621)
• Verification of Alternate Retirement Plan (SFN 53863)
• TFFR Payroll Deduction Authorization (SFN 19182)
• Request to Cancel Retiree Health Insurance Coverage (SFN 58269)
• Group PDP Disenrollment Form
• Medicare Prescription Drug Plan Enrollment Form

Publications for Retirees

• Certificate of Insurance: Dakota Plan - Grandfathered - (Non-Medicare)
  • Summary of Benefits & Coverage - Grandfathered
• Dakota Plan - Non-Grandfathered - (Non-Medicare)
  • Summary of Benefits & Coverage - Non-Grandfathered
• Certificate of Insurance: Dakota Retiree Plan - (Medicare)
  • Dakota Retiree Plan (Medicare)
  • BCBS Notice of Change in Medicare 2013
  • Medicare Blue Rx Member Handbook
  • Medicare Blue Rx Summary of Benefits 2013
  • Medicare Part D Questions & Answers
  • Prescription Drug Creditable Coverage
• Guide to Explanation of Benefits
• Is Case Management for You?