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Below are the current versions of most common provider forms. Please check forms in your office to ensure your versions are the most up-to-date. To order a large supply of forms or to order materials not listed on this page, use the Iowa  (123KB) or South Dakota (113KB) Provider Forms Order Form. |
Electronic Claim Registration Forms
Enrollment/Participation Forms
These forms, excluding the W-9 form, can be completed online. Then you can print, sign and send to Wellmark for processing.
- Statewide Universal Practitioner Application
- Professional Provider Application
- Statewide Universal Facility Application
- W-9 Form (250KB)
- Facility Application #S-3620 (571KB) - South Dakota only
- Participation Agreements for Practitioners
- Participation Agreements for Facilities/Entities
Member Workers’ Comp/COB Questionnaires
- Member Coordination of Benefits Questionnaire
- Workers' Compensation/Subrogation Combination Questionnaire
Paper Claim Forms
Pilot on Quality Physical Medicine Forms
Use the Extension of Care Plan to request additional services or visits beyond what was outlined in the Initial Care Plan, or to report a change in a patient's condition or diagnosis.
Use the Discharge Outcome Summary form to report final diagnosis if different from initial diagnosis, patient overall improvement, referral to other services.
Prior Authorization Pharmacy Forms/Treatment Requests
(These forms can be completed online, but you must print and fax the forms to 1-866-884-4345.)
- Afinitor (everolimus) P-23253 (69KB)
- *Amevive (alefacept) - #P-23172 (132KB)
- Amitiza® (lubiprostone) - #P-23149 (100KB)
- Anti-Migraine Agents - #M-23124 (136KB)
- *Avastin (bevacizumab) - #P-23171 (95KB)
- *Avonex Rebif (interferon beta-1a) - #P-23245 (102KB)
- Banzel (rufinamide) - #P-23209 (71KB)
- *Betaseron (interferon beta-1b) - #P-23245 (102KB)
- *Botox Myobloc (botulinum toxin)- #P-23168 (75KB)
- Brand Fibrate (Antara, Fenoglide, Lipofen, Tricor, Triglide, Trilipix) - #P-23236 (85KB)
- Brand SSRIs and SSNRIs (Cymbalta, Effexor XR, Lexapro, Luvox CR, Pexeva, Prozac Weekly, Venlafaxine ER) - #P-23237 (113KB)
- Byetta® (exanatide) - #P-23150 (111KB)
- Celebrex® (celecoxib) (118KB)
- Cervarix (HPV vaccine) - #P-23138 (104KB)
- Cimzia (certolizumab) - #P-23167 (119KB)
- Contraceptives (Oral, Transdermal, Intravaginal Ring) - #M-23155 (108KB)
- *Copaxone (glatiramer acetate) - #P-23245 (102KB)
- Daytrana - #P-2322 (106KB)
- Dose Optimization Program - #P-13241 (107KB)
- *Enbrel (etanercept) - #P-23165 (138KB)
- *Erbitux (cetuximab) P-23191 (74KB)
- Gardasil (human papilloma virus vaccine) - #P-23138 (104KB)
- *Growth Hormone - #P-23164 (114KB)
- *H.P. ACTHAR GEL® (corticotropin) - #P-23200 (71KB)
- *Herceptin (trastuzumab) P-23244 (1091KB)
- *Humira (adalimumab) - #P-23163 (176KB)
- * IV and SC Immune Globulins (IVIG) - #P-23160 (102KB)
- *Increlex (mecasermin) - #P-23162 (94KB)
- *Infergen (interferon alphacon-1) - #P-23161 (95KB)
- Kineret (anakinra) - #P-23151 (127KB)
- Kuvan (sapropterin dihydrochloride) - #P-2387 (114KB)
- Lamisil (terbinafine), Penlac (ciclopirox), Sporanox (itraconzaole) and CNL8 (ciclopirox) - #P-2366 (87KB)
- Leukotriene Modifiers - #M-23156 (144KB)
- Long-Acting Opioids – #P-23229 (110KB)
- Noxafil (posaconazole) and Vfend (voriconazole) - #M-23138 (104KB)
- Nuvigil - #M-23157 (300KB)
- Oral Erectile Dysfunction (ED) Medications - #M-23153 (672KB)
- Oral Fentanyl Agents – #P-23228 (113KB)
- *Orencia (abatacept) - #P-23173 (110KB)
- *Pegasys Peg-Intron (peginterferon alpha 2a and peginterferon alfa 2b) - #P-23159 (116KB)
- Prevacid Napra PAC - #M-23154 (278KB)
- Pristiq (desvenlafaxine) - #P-23124 (128KB)
- Progesterone Compounds - #M-23128 (343KB)
- Promacta (eltrombopag) - #P23251 (135KB)
- Proton Pump Inhibitors (PPIs) - #M-23104 (123KB)
- Provigil - #M-23157 (300KB)
- Psychostimulants (hawk-i) - #M-23213 - Iowa only (263KB)
- Relistor® (methylnaltrexone bromide) - #P-23148 (96KB)
- *Remicade (infliximab) - #P-23156 (81KB)
- Requip XL (ropinirole) - #P-23202 (70KB)
- Revatio (sildenafil) - #P-2319 (269KB)
- *Rituxan (rituximab) - #P-23157 (114KB)
- Sedative Hypnotics - #P-2365 (112KB)
- Simponi (golimumab) - #P-23252 (96KB)
- Sprycel (dasatinib) - #P-2321 (31KB)
- *Synagis (palivizumab) - #P-23155 (302KB)
- Tasigna (nilotinib) - #P-2369 (128KB)
- Topical Retinoids/Retinoid-Like Agents - #M-23135 (81KB)
- Treximet (sumatriptan/naproxen) - #P-23203 (112KB)
- Tykerb® (lapatinib) - #P-2363 (128KB)
- *Tysabri (natalizumab) - #P-23153 (119KB)
- Uloric (febuxostat) #P-23255 (97KB)
- *Vectibix (panitumumab) - #P-23190 (74KB)
- Wellbutrin SR and Wellbutrin XL (bupropion extended-release) - #M-23139 (149KB)
- Xenazine (tetrabenazine) – #P-23208 (94KB)
- *Xolair (omalizumab) - #P-23152 (105KB)
- Xyzal (levocetirizine) - #P-2367 (90KB)
*View the medical policies associated with these drugs.
Prior Approval Medical Forms
Provider Appeal Forms
Learn more about the provider post-service appeal process.
Note: The post-service provider appeal process does not apply to overpayment recovery requests. If you have received an overpayment recovery request and do not agree with our reasons for requesting the refund, submit an overpayment recovery appeal. Submit your appeal request before the anticipated overpayment recovery is completed by using the Iowa (155KB) or South Dakota (160KB) Overpayment Recovery Appeal for CMS-1500 Billers. If you are asking that we request a refund, please submit an inquiry using the Provider Inquiry form for Iowa (117KB) or South Dakota (124KB).
Radiology Preauthorization Forms
Referral Forms
Miscellaneous Forms
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