2501 Bell Avenue, Des Moines, IA 50321

Below you will find the annual continued eligibility form that we need you to submit as soon as possible. Please note that these forms are for the 2021 plan year. The forms you completed for 2020 are separate from this update. It is necessary to have the most up-to-date information on file for each person in your family on an annual basis.

Please complete the form as soon as possible. A delay in claim processing will occur if we have not received your submission by December 31, 2020.

Please feel free to contact our office if you have any questions or need additional information! Thanks for your cooperation.