Health Insurance Forms for Retired Members

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:

Enrollment or Cancellation of Coverage

Continuation of Group Insurance Coverage - COBRA

• Continuation of Group Insurance Coverage - COBRA (SFN 14120)
• Retiree Continuation of Group Health Insurance Coverage - COBRA (SFN 53799)

Dakota Plan (Non-Medicare) Enrollment

• Retiree Group Health Insurance Application (SFN 16277)

Dakota Retiree Plan (Medicare) Enrollment

• Retiree Health Insurance with Medicare Application (SFN 59562)
• Medicare Prescription Drug Plan Enrollment Form (SFN 58860)

Disenrollment 

• Request to Cancel Retiree Health Insurance Coverage (SFN 58269)
• Medicare Prescription Drug Plan Disenrollment Form (SFN 58861)

Dependent Disability

• Application for Dependent Disability (SFN 58856)
• Physician's Form for Dependent Disability (SFN 58798)

Access to Communications - Protected Health Information

• Authorization for Use or Disclosure of Protected Health Information (SFN 58769)
• Participant's Authorization to Disclose Protected Health Information (SFN 58770)
• Request to Access Protected Health Information (SFN 58771)
• Participant Request for Confidential Communications (SFN 58772)
• Request for Restrictions On Use and/or Disclosure of Protected Health Information (SFN 58773)
• Health Care Information Release Accounting Form (SFN 58768)

Other general forms

• Authorization to Release Confidential Information (SFN 61324)
• Notice of Change for Name & Address (SFN 10766)
• Authorization for Automatic Premium Deduction (SFN 50134)
• Verification of Alternate Retirement Plan (SFN 53863)