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Retiree Health and/or Dental Insurance Applications
- Application for the Retired/Disabled Health and Dental Insurance Group (171.86 KB) .pdf
- Cancellation of Retiree Health and/or Dental Insurance (195.49 KB) .pdf
Sick Leave Insurance Program (SLIP)
- SLIP Enrollment Form
- SLIP Calculation Estimate Worksheet (22.5 KB) .xls
- SLIP Retiree Rehire Authorization (50.1 KB) .docx
Applications and Forms
Retiree Applications
Wellmark State of Iowa Retiree Application (624.4 KB) .pdf
Group MedicareBlue Rx for Iowa Application (1.26 MB) .pdf (for Group Program F or N)
Group MedicareBlue Rx for Iowa Application (1.26 MB) .pdf (for Iowa Choice/National Choice)
Delta Dental Application (1021.85 KB) .pdf Delta Dental Application (fillable pdf form) (955.47 KB) .pdf
Electronic Funds Transfer (EFT) Forms
Wellmark Automatic Payment Authorization (455.43 KB) .pdf
Group MedicareBlue Rx Automatic Payment Authorization (183.63 KB) .pdf
Delta Dental Automatic Payment Authorization (52.23 KB) .pdf
Contact Information
- Department of Administrative Services, Human Resources Enterprise - 866-895-2464 or stateretirees@iowa.gov
- Wellmark, Blue Cross Blue Shield of Iowa – Customer Service - 800-622-0043
- MedicareBlue Rx – Customer Service - 877-838-3827
- Medicare website - www.medicare.gov/
- Senior Health Insurance Information Program (SHIIP) - 800-351-4664 or shiip.iowa.gov/
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