Forms

Health Insurance Forms

Blue Scross Blue Shield

• Authorized Representative Form
• Automatic Withdrawl – On-Exchange
• Automatic Withdrawl – Off-Exchange
• Cancellation Form

Medica - Individual and Family Business (IFB)

• Automatic Payment Form
• Policy Cancellation Form

Medica – Prime Solutions

• Change Form
• Automatic Payment Form
• Medical Services Reimbursement
• Dental, Eyewear and Hearing Aid Reimbursement
• Medicare Part D Prescription Drug Claim Form
• Electronic Funds Transfer Form - Medica Prime Solution and Medica Group Prime Solutions w/Rx
• Electronic Funds Transfer Form - Medica Advantage Solution, Advantage and Group Advantage Solution
• Authorization to Disclose Protected Health Information to Designated Individual or Representative
• Senior Dental Disenrollment

Sanford Health Plans

• Change/Cancellation Form
• ACH Form - Marketplace
• ACH Form - Off-Exchange
• Automatic Payment Authorization Form

Ameritas Life Insurance

• Electronic Funds Transfer Authorization

NDPERS

• Retiree Health Insurance Credit Program Claim Form

Next Blue

• Request for Reimbursement Form
• Medicare Part D Claim Form
• Medicare Advantage Plans Authorization Agreement for Automatic Payment Withdrawal
• Dental Reimbursement Form

Please note if we do not have the form you need, contact us at info@witthauerfinancialgroup.com or call 701-252-8000.