Electronic Claim Transaction Registration/Enrollment Forms
These forms, excluding the W-9 form, can be completed online. Then you can print, sign and send to Wellmark for processing. Note: To avoid delays in processing your application or contract, please access updated documents using the links below. Please dispose of any paper stockpile you may have. Wellmark’s contracts have been updated to reflect a change in signature authority, while other addendums or applications now request additional information.
- Statewide Universal Practitioner Application
- Professional Provider Application - Complete and return a W-9 with this application
- Statewide Universal Facility Application
- W-9 Form
- Participation Agreements for Practitioners
- Participation Agreements for Facilities/Entities
Member Related Forms and Questionnaires
- Member Coordination of Benefits Questionnaire
- Workers' Compensation Questionnaire
- My Prescription for You
- Authorization to Use or Disclose Protected Health Information
Personal Representative Appointment
Paper Claim Forms
- Pharmacy Exception Requests for Non-Formulary Medications
A non-formulary drug is a drug that is not covered under a prescription drug plan because cost-effective alternatives are available under the formulary drug coverage.
If you need to prescribe a non-formulary medication, complete the Exception Request form and fax it to the number on the form.
Note: This form is different than a prior authorization request, which allows Wellmark to verify a prescription drug is part of a specific treatment plan and is medically necessary.
Formulary Exception Request #P-23282
- Prior Authorization Pharmacy Forms
The following forms can be completed online, but you must print and fax the forms to 1-866-884-4345.
*View the medical policies associated with these drugs.
- Member Specialty Pharmacy Enrollment Forms
Physical Medicine Form
Prior Approval Medical Forms
- Prior Approval Form (To determine when to complete this form, visit Important Authorization Terms. These forms are only to be used for non-contracting or out-of-state providers. Contracting providers need to use the online Utilization Management Tool.)
Provider Claim Review Forms
Learn more about the provider post-service appeal process.
- Provider Inquiry Form (initial step in claim review process)
- Provider Post-Service Appeal Form (second step in claim review 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.
To submit out of network and referral requests, use the online Utilization management tool. Please refer to the Quick Start Guide .