Medicare Part-D Forms

Forms Policy

1. Digital signatures are not accepted by NDPERS.
2. Completed forms must be submitted to NDPERS by fax, by mail, or as a scanned PDF.
3. NDPERS does not accept picture files such as .jpeg, .jpg, .tif, or .png.

Select a form to download:

• Humana - Medicare Prescription Drug Plan (PDP) Individual Enrollment (SFN 58860)
• Prescription Drug Plan (PDP) Disenrollment (SFN 58861)
• Retiree Health Insurance with Medicare Application (SFN 59562)

Other general forms:

• Authorization to Release Confidential Information (SFN 61324)
• Notice of Change for Name & Address (SFN 10766)