Form N-5423 - Personal Doctor Selection Form - Wellmark Iowa

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Send completed form to:

Wellmark Health Plan of Iowa, Inc.

Failure to fill out this form completely may result in a delay of coverage

Station 3W190

and issuance of ID cards.

PO Box 14527

Des Moines, IA 50306-3527

Personal Doctor Selection Form

Fax to: 515-376-9045

Use this form to elect your Personal Doctor.

E-mail to:

• A Personal Doctor must be chosen for each family member; females may also select a participating OB/GYN. (If an OB/GYN is not selected, your Personal Doctor should provide these

services.)

• You may change your Personal Doctor or OB/GYN by submitting this form or calling the customer service number on your ID Card. Personal Doctor selection changes will be effective the

first of the month following receipt of your request.

A. Enrollee Information

Name (First, Middle, Last): _______________________________________________________________

Social Security Number: ________________________________

Address: ______________________________________________________________________________

Telephone: (_________) _______________________________

City: __________________________________________________________________________________

State: ___________________

Zip: _____________________

B. Personal Doctor Selection

OB/GYN

Personal Doctor

Personal

Date of

Personal Doctor

Are you an

Personal

Are you an

Gender

Personal Doctor

Address

Full Name (First,

Provider

Doctor

Birth

Name

established

Doctor -

established

(Check

Name

(Office location

Middle, Last)

Number

Address

(Office

one)

MM/DD/YY

(First and Last Name)

where you will

patient?

Provider

patient?

(First and Last

location where you

receive services)

Name)

Number

will receive services)

Enrollee

 M

 Yes

__ __ __ __ __

 F

 No

Spouse

 M

 Yes

__ __ __ __ __

 F

 No

Dependent

 M

 Yes

__ __ __ __ __

 F

 No

Dependent

 M

 Yes

__ __ __ __ __

 F

 No

Dependent

 M

 Yes

__ __ __ __ __

 F

 No

Dependent

 M

 Yes

__ __ __ __ __

 F

 No

HMO and Blue Rewards plans require a Personal Doctor be selected.

If you are not an established patient, you will need to determine if this Personal Doctor is accepting new patients. If the provider you listed is not accepting new patients, you will need to

select a different Personal Doctor. To access a Provider Directory, see

C. Certification and Signature

I certify that I am legally authorized to assign a Personal Doctor for myself and on behalf of all other persons named in this Personal Doctor Selection Form.

Enrollee Signature: _______________________________________________________________________________________ Date: ______/______/______

N-5423 10/15