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| |  Printer-Friendly Page | | Forms
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. 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 (250KB)
- Participation Agreements for Practitioners
- Participation Agreements for Facilities/Entities
Member Workers’ Comp/COB Questionnaires
- Member Coordination of Benefits Questionnaire
- Workers' Compensation Questionnaire
My Prescription for You
Paper Claim Forms
Physical Medicine Form
Prior Authorization Pharmacy Forms/Treatment Requests
For hawk-i members: If you need to prescribe a medication not found on the hawk-i Drug List, complete the exception request and fax to the number on the form. Unless Wellmark approves a medical exception, hawk-i members are responsible for the full cost of branded medications not included on the hawk-i Wellmark Drug List.
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.
Prior Approval Medical Forms
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.
- Overpayment Recovery Appeal Form for CMS-1500 Billers
Radiology Preauthorization Forms
Referral Forms
Miscellaneous Forms
To order a large supply of forms or to order materials not listed on this page, use the Provider Forms Order Form.
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