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.

2010 Applications

• HIPIOWA Application Packet

2010 Premiums

• PPO Non-Tobacco User
• PPO Tobacco User

2009 Premiums

• Medicare Carve-out
• PPO Non-Tobacco User
• PPO Tobacco User

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"
• Claim Form Non-Medicare
• Tobacco user Affidavit

Appeals and Grievance Procedure

• Appeals and Grievance Procedure

2005 Policy

• 2005 Policy
• Maternity Benefits Rider

Outline of Coverage

• Outline of Coverage

Outline of Benefit Plan

• PPO Plans
• Carveout

Survey for Iowa Comprehensive Health Assoc.

• Frequently Asked Questions
• Iowa Survey

Misc.

• HIPIOWA Privacy Notice