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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 pdf or South Dakota pdf Provider Forms Order Form.

Electronic Claim Transaction Registration/Enrollment 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.

Member Related Forms and Questionnaires

Paper Claim Forms

Pharmacy Forms

*View the medical policies associated with these drugs.

Physical Medicine Form 

Prior Approval Medical Forms 

Provider Claim Review 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.

Referral Forms

To submit out of network and referral requests, use the online Utilization management tool. Please refer to the Quick Start Guide pdf.

Miscellaneous Forms 



WINS

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