To view, click on the name of the form listed below.

• Authorization for Use and Disclosure of Health Information Form
• Claim Form
• COBRA Enrollment Form
• DAKOTACARE Direct Deposit Authorization Form
• DAKOTACARE Flex Orthodontia Claim Form
• Direct Payment Plan Form
• Family Status Change Form
• Incapacitated Dependent Child Form
• Life Enrollment Form
• RETIREE Enrollment Form
• RETIREE (65+) Enrollment Form
• Student Verification Form
• Tobacco Use Election Form
• Waiver of Life Premium Form

• Express Scripts (ESI) Prescription Drug Claim Form
• ESI Formulary List Look Up
• FY 2012 Formulary
• FY 2012 Formulary Changes FAQ
• Maintenance Drug List

• Bundled Payment Procedures and Facilities
• Contracted Facilities for MRI and CT Scans
• FY 2012 Annual Enrollment Guide
• FY 2012 and FY 2013 Health Plan Comparison Chart
• Health Assessment
• Health Screening
• HIPAA
• Pre-authorization Listing

• $300 Deductible/Copay Plan
• $1,000 Deductible Plan
• $2,000 Deductible Plan HSA Compatible
• Health Assessment
• Healthy Employees
• Health Screening
• Latitude Program
• Prescription Drug FAQ for $300 Deductible/Copay and $1,000 Deductible Plans
• Tobacco Free