Dear
Plan Member ID:
Plan Member Group #:
Claim #:
Date _____/_____/_____
Your contract contains a Coordination of Benefits clause. In order to process your claims, the following current information
is required:
While you have been covered by Wellmark, have you or any of your family members been covered by another:
Health Plan Yes No Dental Plan Yes No Prescription Plan Yes No
If No, you must do one of the following:
• Sign, date, and return this form by mail or FAX to 515-376-9097.
• Call Customer Service at the phone number on your ID card.
• Federal Employees (ID Number beginning with “R”), call 800-532-1537 (Weekdays 7:30 a.m. - 5:00 p.m.).
If you have any questions, please call our Customer Service department at the phone number on your ID card.
If Yes, please provide the required information below and return this letter by mail or FAX to 515-376-9097.
Complete name and address of other insurance company:
Other insurance company phone #:
Policyholder’s name with other insurance:
Policyholder’s date of birth with other insurance:
Identification number with other insurance:
___________________________________________________
(_____) _____________________________________________
___________________________________________________
_____/_____/_____
___________________________________________________
Is there a divorce decree/court order that requires one or both parents to provide health insurance for any covered dependents?
Yes No If yes, a copy of the divorce decree/court order is required and will only be used for claims processing. If one
has already been provided, you do not need to send another copy.
Person(s) required to carry health insurance per divorce decree/court order:
First Name Last Name
_____________________________________________ _________________________________________________
_____________________________________________ _________________________________________________
Person with primary physical custody: _________________________________________________________________
If you or any member of your family are eligible for Medicare, please provide the required information below as it appears exactly
on the Medicare card.
Name of eligible persons: _________________________________________ Medicare HIC #: ____________________
Eective date(s): Part A: ______/______/______ Part B: ______/______/______ Part D: ______/______/______
_________________________________________________________________________ ______/______/______
(Member Signature) (Date)
Federal Employees Only: Warning - Any intentional false statement or willful misrepresentation is a violation of the law punishable by a fine
not more than $10,000 or imprisonment of not more than 5 years, or both (18 U.S.C. 1001).
C-3508 5/13
Wellmark Blue Cross and Blue Shield of South Dakota | 1601 West Madison Street | Sioux Falls, South Dakota 57104 | Oce: 605.373.7200 | wellmark.com
