- Digital signatures are not accepted by NDPERS.
- Completed forms must be submitted to NDPERS by fax, by mail, or as a scanned PDF.
- 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)
- 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)