Health Insurance Forms for Active 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

• Health Insurance Application or Change (SFN 60036)
• Continuation of Group Insurance Coverage (COBRA) (SFN 14120)
• Acknowledgement of or Decline Offer of Health Insurance Coverage (SFN 60711)
• Authorization for Automatic Premium Deduction (SFN 50134)

Dependent Coverage

• Grandchild Eligibility Verification (SFN 60983)
• Application for Dependent Disability (SFN 58856)
• Physician's Form for Dependent Disability (SFN 58798)

Access to Communications - Protected Health Information

• Health Care Information Release Accounting Form (SFN 58768)
• 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)

Other general forms

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