Annual Questionnaire for Other Health Insurance Verification

To prevent claim delays, please use this Other Health Insurance Verfication form [PDF] to complete your Annual Questionnaire for Other Health Insurance Verification annually to provide us with a health coverage update for you or your dependents. The information requested will enable us to coordinate payment of your claim when other insurance is present.

Please return the form to HealthSmart (formerly Wells Fargo TPA) by mail or fax.

Mailing Address and Fax number:

• HealthSmart (formerly Wells Fargo TPA)
• P.O. Box 99004
• Anchorage, AK 99509-9004
• Fax: (304) 353-8636