Member Health Coverage Forms

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

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
Out-of-Area Residence Form – to request in-network benefits for dependents enrolled in Avera Health Plans and reside outside our coverage area for more than 90 consecutive days

Cost Estimate
Flexible Spending & Health Savings Account forms – provided by DAKOTACARE Administrative Services (DAS)
Prescription reimbursement – Log in to the CVS Member Portal to access a digital form or use this Prescription Reimbursement Claim Form
Medical Reimbursement Claim Form: Individual Providers
Prescription Mail Order Form
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

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
Out-of-Area Residence Form – to request in-network benefits for dependents enrolled in Avera Health Plans and reside outside our coverage area for more than 90 consecutive days
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

Cost Estimate Request
Flexible Spending & Health Savings Account forms – provided by DAKOTACARE Administrative Services (DAS)
Prescription reimbursement – Log in to the CVS Member Portal to access a digital form or use this Prescription Reimbursement Claim Form
Prescription Mail Order Form
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

See all of our member resources online.