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
• Member Workers’ Comp/COB Questionnaires
• Paper Claim Forms
• Physical Medicine Forms
• Prior Authorization Pharmacy Forms/Treatment Requests
• Prior Approval Medical Forms
• Provider Claim Review Forms
• Radiology Preauthorization Forms
• Referral Forms
• Miscellaneous Forms

Electronic Claim Registration Forms 

• Electronic Transaction Registration Packet #S-53260  (563KB)
• Create & Submit Claims Submitter Number Registration Form for Wellmark Professional Claims #K-2307  (245KB)

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
  • Iowa  (2.73MB)
  • South Dakota  (4.61MB)
• Professional Provider Application
  • Iowa  (476KB) 
  • South Dakota  (580KB) 
• Statewide Universal Facility Application
  • Iowa  (775KB) 
    • Supplemental Financial Form  (25KB)
  • South Dakota  (580KB) 
    • Supplemental Financial Form #S-3621  (67KB)
• W-9 Form  (250KB)
• Participation Agreements for Practitioners
  • Iowa
  • South Dakota
• Participation Agreements for Facilities/Entities
  • Iowa
  • South Dakota

Member Workers’ Comp/COB Questionnaires

• Member Coordination of Benefits Questionnaire
  • Iowa  (63KB)
  • South Dakota  (63KB)
• Workers' Compensation/Subrogation Combination Questionnaire
  • Iowa #C-5347  (113KB)
  • South Dakota #C-3509  (112KB)

Paper Claim Forms

• Medical Claim Filing #CMS-1500  (239KB)
• Facility Claim Uniform Bill #UB-04  (271KB)
• Second Opinion Claim Form #C-4312 - Iowa only (20KB)

Physical Medicine Forms 

• Physical Medicine Treatment Plan (for anticipated services over 20 visits)
• Pilot on Quality Physical Medicine Forms (for physical medicine providers participating in the Pilot on Quality)
  • Initial Care Plan #S-2306  (216KB)- Use the Initial Care Plan after a member’s first visit.
  • Extension of Care Plan #S-2307  (187KB) - 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.
  • CoQ^® Physical Medicine Discharge/Outcomes of Care #S-2313  (138KB) - 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  (103KB)
• Amitiza® (lubiprostone) #P-23149  (100KB)
• Anti-Migraine Agents #M-23124  (88KB)
• *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) & Victoza (liraglutide) #P-23150  (111KB)
• Celebrex® (celecoxib) #M-2382  (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  (119KB)
• *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)
• Intuniv #P-23263  (105KB)
• 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  (100KB)
• Oral Erectile Dysfunction (ED) Medications #M-23153  (672KB)
• Oral Fentanyl Agents #P-23228  (113KB)
• *Orencia (abatacept) #P-23173  (110KB)
• Parkinsons Disease (RequipXL & Mirapex ER) P-23264  (104KB)
• *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  (100KB)
• Psychostimulants (hawk-i) #M-23213 - Iowa only (263KB)
• Relistor^® (methylnaltrexone bromide) #P-23148  (96KB)
• *Remicade (infliximab) #P-23156  (77KB)
• 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  (87KB)
• 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 

• Cognitive Rehabilitation Treatment Plan #P-2316  (86KB)
• Outpatient Treatment Report #C-5364  (150KB)
• hawk-i Provider Exception Form #P-4307  (122KB)
• Prior Approval Form (To determine when to complete this form, visit Authorizations.)
  • Iowa - Medical #P-4602  (158KB)
  • South Dakota - Medical #N-3614  (140KB)
  • FEP (Federal Employee Program) Medical/Surgical Prior Approval Form #P-4306  (112KB)
• Physician Certification for Morbid Obesity Surgery
  • Iowa - #P-5341  (61KB)
  • South Dakota - #P-3317  (45KB)
• PT or OT Evaluation Form #S-2308  (183KB)

Provider Claim Review Forms

Learn more about the provider post-service appeal process.

• Provider Inquiry Form (initial step in claim review process) 
  • Iowa - #B-5403  (118KB)
  • South Dakota - #B3402  (125KB)
• Provider Post-Service Appeal Form (second step in claim review process)
  • Iowa - #S-53259  (110KB)
  • South Dakota - #S-3317  (114KB)
• External Review (final step in claim review process)
  • Physician Billing Dispute Request Form  (MES Solutions site)
  • Physician Medical Necessity, Experimental, or Investigational External Review – Provider Request Form (MRIoA site)

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
  • Iowa - #B-5366  (155KB)
  • South Dakota - #B-3316  (160KB)

Radiology Preauthorization Forms 

• Radiology Preauthorization Fax Form  (99KB)
• Oncologic PET Scan Fax Form  (54KB)

Referral Forms

• One Call Connect Referral Request #P-23100  (130KB), One Call Connect Program Overview
• Wellmark Health Plan of Iowa Referral Form #M-8721 - Iowa only (91KB)

Miscellaneous Forms 

• Accommodative Intraocular Lens Implant Waiver
  • Iowa  (14KB)
  • South Dakota  (14KB)
• Authorization to Use or Disclose Protected Health Information
  • Individual Authorization
    • Iowa - #S-53258  (206KB)
    • South Dakota - #S-3315  (207KB)
  • Designation of Authorized Representative
    • Iowa - #S-53257  (159KB)
    • South Dakota - #S-3316  (161KB)
• Authorized Representative Appointment and Authorization for Release of Information
  • Iowa - #C-5674  (41KB)
  • South Dakota - #C-3617  (37KB)
• Back-up Physician Change Form - Iowa only (21KB)
• Caremark Specialty Pharmacy Enrollment Form  (653KB)
• Change Form (address, Tax ID; a completed W-9 Form  (251KB) must accompany any Tax ID change)
• Hospital Privileges Update Form  (218KB)
• Problem List/Past Medical History Medical Record Keeping Aid #S-2600  (206KB)
• Provider Inquiry Forms: See Provider Claim Review Forms

To order a large supply of forms or to order materials not listed on this page, use the Provider Forms Order Form.