Retiree Applications and Forms

Retiree Health and/or Dental Insurance Applications 

• Application for the Retired/Disabled Health and Dental Insurance Group 
• Cancellation of Retiree Health and/or Dental Insurance

Sick Leave Insurance Program (SLIP)

• SLIP Enrollment Form
• SLIP Calculation Estimate Worksheet
• SLIP Retiree Rehire Authorization

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 

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/