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.

Member Workers’ Comp/COB Questionnaires

Paper Claim Forms

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)

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.)

*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.

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.

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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Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota.
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