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
• Employer Participation Agreement Renewal for Small Employer
• 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

We appreciate your interest in becoming an Avera Health Plans approved agent. To start the process, please complete and submit the forms below.

• 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