HIPIowa: Download Forms

Download Forms

All of the forms listed below are in PDF format which allows you to view them electronically on most computers. The Adobe Acrobat reader is required to view and print PDF files. If you do not have the reader, click here to download free of charge.

2008 Applications

HIPIOWA Application Packet

2008 Premiums

Medicare Carve-out

PPO Non-Tobacco User

PPO Tobacco User

2007 Premiums

Medicare Carveout Plan E (Eff. Jan. 1, 2007)

Premium Rates Plans B, C, D, F and G. Non Tobacco User (Eff. Jan. 1, 2007)

Premium Rates Plan B, C, D, F and G. Tobacco User Eff. Jan 2007)

Forms

Automatic Bank Withdrawal Authorization
Member Change Form
Personal Representative Form - used to provide permission to the health plan to release information on an ongoing basis to an individual acting as the member's "personal representative"

Appeals and Grievance Procedure