- 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
Continuation of Group Insurance Coverage - COBRA
- Continuation of Group Insurance Coverage - COBRA (SFN 14120)
- Retiree Continuation of Group Health Insurance Coverage - COBRA (SFN 53799)
Dakota Plan (Non-Medicare) Enrollment
Dakota Retiree Plan (Medicare) Enrollment
- Retiree Health Insurance with Medicare Application (SFN 59562)
- Medicare Prescription Drug Plan Enrollment Form (SFN 58860)
- Request to Cancel Retiree Health Insurance Coverage (SFN 58269)
- Medicare Prescription Drug Plan Disenrollment Form (SFN 58861)
- Application for Dependent Disability (SFN 58856)
- Physician's Form for Dependent Disability (SFN 58798)
Access to Communications - Protected Health Information
- 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)
- Health Care Information Release Accounting Form (SFN 58768)