AlaskaCare Retiree Forms
Verification/Certification Forms
- Other Health Insurance Verification
- Other Health Insurance Verification form [PDF 116K]
- Complete this form annually to report any other health coverage (including Medicare) you or your dependents may have. Failure to provide this proof to HealthSmart (formerly Wells Fargo TPA) annually can cause delays in paying your claims.
- Student Status Verification form
- Student Status Verification form [PDF 75K]
- For claims incurred prior to July 1, 2011, verification of student status is required semi-annually.
- Request for Certification of Incapacitated Dependent
- Request for Certification of Incapacitated Dependent [PDF 89K]
- Complete and submit if your dependent has been awarded Social Security benefits