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Avera Health Plans Forms and Brochures

Below is a list of forms and brochures that you may find useful. If you don’t see the information that you are looking for, please contact the Avera Health Plans Service Center Monday-Friday, 8 a.m. - 5 p.m. CT, at (605) 322-4545 or toll-free at 1 (888) 322-2115.

Employer Group Forms

Authorization Representative Appointment
Change Form
Coordination of Benefits Fully Insured Members
EFT-ACH Withdrawl Form
Employer Participation Agreement (New Groups)
Employer Participation Renewal Agreement
Enrollment Application Fully Insured Groups
Enrollment Application (Spanish) Fully Insured
Flex Claim for Reimbursement Form
Flex Election Change Form
Flex Enrollment Form
Out-of-Area Dependent Residence Registration Form
Student Verification Form
Termination of Coverage Form

Agent (Fillable) Forms

Educational Materials for Employers and/or Members

Avera MyPlan Member Forms

Avera MyPlan Enrollment Application
Avera MyPlan Change Form
Avera MyPlan Coordination of Benefits Form
Avera MyPlan EFT-ACH Withdrawl Form

Updates on Health Care Reform