Retiree Health and/or Dental Insurance Applications 

Sick Leave Insurance Program (SLIP)

Applications and Forms  

Retiree Applications

Wellmark State of Iowa Retiree Application

Iowa Group MedicareBlue Rx Application  (for Group Program F or N)

Iowa Group MedicareBlue Rx Application (for Iowa Choice/National Choice) 

Delta Dental Application  

Electronic Funds Transfer (EFT) Forms

Wellmark Automatic Payment Authorization

Group MedicareBlue Rx Automatic Payment Authorization  

Delta Dental Automatic Payment Authorization 

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Contact  Information  

  • Department of Administrative Services, Human Resources Enterprise - 866-895-2464 or
  • Wellmark, Blue Cross Blue Shield of Iowa – Customer Service - 800-622-0043
  • MedicareBlue Rx – Customer Service - 877-838-3827
  • Medicare website -
  • Senior Health Insurance Information Program (SHIIP) - 800-351-4664 or