Member Health Coverage Forms

Need to update information related to your health plan? You can download, fill out and submit forms found here.

Members

Plan and Information Updates

Authorization Agreement for Automatic Bank Withdrawal form – set up automatic bank withdrawal for your monthly premium payment. Email CustomerExperience@avera.org to request to complete the form electronically through DocuSign.
Authorization for Access of Health Information – if you 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)
Change Form for Individual Health Insurance – for Individual or Family policyholders who enrolled directly with Avera Health Plans and want to update their address, phone number, name or to cancel a policy
- NOTE: If you applied through Healthcare.gov, please contact the federal Marketplace at 1-800-318-2596.
Change Form for Medicare Supplement Policies – to make name, address or phone number updates or cancel a policy
Individual/Family Plan: Coordination of Benefits Form – for Individual policyholders with overlapping coverage

Estimates, Claims and Appeals

Cost Estimate
Flexible Spending & Health Savings Account forms – provided by DAKOTACARE Administrative Services (DAS)
Prescription reimbursement – Log in to the Avera Health Plans member portal to access our pharmacy tool, Avera Health Plans Rx. By logging in, you have access to information for your specific plan. You can also use the Prescription Reimbursement Claim Form for 2025 claims (pdf). Prescription Reimbursement Claim Form for 2024 claims (pdf)
Medical Reimbursement Claim Form: Individual Providers
Member Appeal Form – file an appeal on a claim/authorization denial
Member Appeal Request Form (Marketplace Only) – for on-exchange members to appeal directly through the marketplace
Member Complaint Form – formal member complaint form

Employee Forms

Plan and Information Updates

Authorization Agreement for Automatic Bank Withdrawal form – set up automatic bank withdrawal for your monthly premium payment. Email CustomerExperience@avera.org to request to complete the form electronically through DocuSign.
Authorization for Access of Health Information – if you 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)
Change Form for Employee Plans – for employees enrolled in employer-provided insurance with Avera Health Plans who want to update their address, phone number or name
Employee Plan: Coordination of Benefits Form – for employees enrolled in employer-provided insurance with Avera Health Plans with overlapping coverage
Disabled Adult Dependent Form – to verify your dependent’s eligibility as a disabled adult dependent
Student Verification – to verify full-time student status

Estimates, Claims and Appeals

Cost Estimate Request
Flexible Spending & Health Savings Account forms – provided by DAKOTACARE Administrative Services (DAS)
Prescription reimbursement – Log in to the Avera Health Plans member portal to access our pharmacy tool, Avera Health Plans Rx. By logging in, you have access to information for your specific plan. You can also use the Prescription Reimbursement Claim Form for 2025 claims (pdf). Prescription Reimbursement Claim Form for 2024 claims (pdf)
Member Appeal Form – file an appeal on a claim/authorization denial
Member Appeal Request Form (Marketplace Only) – for on-exchange members to appeal directly through the marketplace
Member Complaint Form – formal member complaint form

Small Group Employers (ACA-Compliant Plans)

Enrollment and Changes

Application for Small Employer Group Enrollment
Application for Small and Large Employer Grandfathered and Non-Grandfathered
- Spanish Application
Beneficiary Election and Change Form ACA - South Dakota groups only
COBRA Services Agreement
Flexible Spending & Health Savings Account forms – provided by DAKOTACARE Administrative Services (DAS)
Sold Checklist for Small Employer
Termination of Coverage Request Form – for employers to complete to terminate coverage for an employee and/or the employee’s dependents

Large Group Employers (ACA & Self-Funded Plans)

Enrollment and Changes

Application for Small and Large Employer Grandfathered and Non-Grandfathered
- Spanish Application
COBRA Services Agreement
New Large Employer Participation Agreement
Open Enrollment Change Form
Quote Request for Large Employer
Renewal for Large Employer Partner
Termination of Coverage Request Form – for employers to complete to terminate coverage for an employee and/or the employee’s dependents

Need Something Else?

See all of our member resources online.

Member Resources Member Portal

Or contact our Customer Service team.

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