Forms

Member Forms

• Authorization for Access of Health Information
  • For those who need to access your dependents’ secured portal (18 years and older) and/or to allow access to your agent, doctor or lawyer so he/she can view your secured medical claims / Explanation of Benefits (EOBs)
  • For online access, all members listed on the form must login and register, including the member authorizing the release of information, before Avera Health Plans can process.
• Automatic Bank Withdrawal Authorization for Monthly Premium Payments
  • For Medicare Supplement and Individual policyholders.
• Change Form - Individual policyholders who enrolled directly with Avera Health plans and want to update their address, phone number, name, to add/remove a dependent or to cancel your policy.
  NOTE: If you applied through healthcare.gov, please contact the Federal Marketplace at 1-800-318-2596.
• Change Form - Medicare Supplement Insurance policyholders who want to update their address, phone number or to cancel your policy.

• Coordination of Benefits Form - Individual policyholders who have overlapping coverage.

• Out-of-Area Residence Form
• Prescription Reimbursement Claim Form
• Prescription Mail Order Form (Learn more about mail orders.)
• Member Appeal Form - File an appeal on a claim/authorization denial.
• Member Appeal Request Form (Marketplace Only) - Appeal form for on-exchange members to appeal directly through the marketplace.
• Member Complaint Form - Formal complain form.

Employer Group and/or Employee Forms

• Automatic Bank Withdrawal Authorization for Monthly Premium Payments
• Change Form - Members who enrolled through your employer and want to update your address, phone number, name, to add/remove a dependent or to cancel your policy, please submit to your employer and they will contact Avera Health Plans with your updates.
• Coordination of Benefits Form
• Disabled Adult Dependent
• Out-of-Area Residence Form
• Student Verification
• Termination of Coverage Request Form

Small Employer Group Forms (ACA Compliant Plans)

• Application for Small Employer Group Enrollment
• Application for Small and Large Employer Grandfathered and Non-Grandfathered
  
  • Spanish Application
• COBRA Services Agreement
• Sold Checklist for Small Employer

Large Employer Group Forms (ACA and Self-funded Plans)

• Application for Small and Large Employer Grandfathered and Non-Grandfathered
  
  • Spanish Application
• COBRA Services Agreement
• Employer Participation Agreement and Renewal for Large Employer
• Sold Checklist for Large Employer
• Quote Request for Large Employer

Flexible Spending Account (FSA) and Health Savings Account (HSA) Forms

• HSA Employer Enrollment Form
• FSA Administrative Services Agreement
• FSA Employer Enrollment Form
• FSA Member Enrollment Form
• Election Change Form for Members (FSA and/or HRA)
• FSA Premium Only Plan (POP) Setup Request
• FSA Request for Reimbursement Form

For Agents Only

• Agent Commission Confirmation
• Commission Direct Deposit Form
• Authorization for Access of Health Information
  • For those who need to access your dependents’ secured portal (18 years and older) and/or to allow access to your agent, doctor or lawyer so he/she can view your secured medical claims / Explanation of Benefits (EOBs)
• COBRA Services Agreement