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  or South Dakota  Provider Forms Order Form.

• Electronic Claim Registration Forms 
• Enrollment/Participation Forms 
• Member Workers’ Comp/COB Questionnaires 
• My Prescription for You 
• Paper Claim Forms 
• Pharmacy Exception Requests 
• Physical Medicine Forms 
• Prior Authorization Pharmacy Forms 
• Prior Approval Medical Forms 
• Provider Claim Review Forms 
• Referral Forms 
• Treo Website Access Request - Provider Payment  
• Miscellaneous Forms 

Electronic Claim Registration Forms 

• Electronic Transaction Registration Packet #S-53260  
• Create and Submit Claims Submitter Number Registration Form for Wellmark Professional Claims #K-2307  

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
  • Iowa  
  • South Dakota  
• Professional Provider Application - Complete and return a W-9 with this application
  • Iowa  
  • South Dakota 
• Statewide Universal Facility Application
  • Iowa  
  • South Dakota   
• W-9 Form  
• 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  
  • South Dakota  
• Workers' Compensation Questionnaire
  • Iowa #C-5518  
  • South Dakota #C-3509  

My Prescription for You

• Adolescent Health  
• Adult Prevention/Screening  
• Adult Lifestyle Change 

Paper Claim Forms

• Medical Claim Filing #CMS-1500  
• Facility Claim Uniform Bill #UB-04  
• Second Opinion Claim Form #C-4312 - Iowa only  

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  

Physical Medicine Form 

• Physical Medicine Treatment Plan (for anticipated services over 20 visits)

Prior Authorization Pharmacy Forms

The following forms can be completed online, but you must print and fax the forms to 1-866-884-4345.

• Adcirca (tadalafil) and Revatio (sildenafil) Fax Form #P-23246  
• ADHD (Non-stimulants) #P-23299  
• Amitiza® (lubiprostone) #P-23149 
• Anti-fungals #P-2366 
• Anti-Migraine Agents #M-23124 
• *Avastin (bevacizumab) #P-23171 
• Banzel (rufinamide) and Onfi (clobazam) #P-23209 

• Betaseron Beta Interferons #P-23245 

• *Biological Immunomodulators #P-23351 
• Brand Fibrate (Antara, Fenoglide, Lopofen, Tricor, Triglide, Tilipix) #P-23236 
• Brand SSRIs and SNRIs (Cymbalta, Lexapro, Luvox CR, Pexeva, Pristiq, Viibryd) #P-23237  
• Celebrex® (celecoxib) #M-2382  
• Contraceptives (Oral, Transdermal, Intravaginal Ring) #M-23155 
• Corticosteroids and LABA Combo Inhalers #P-23324 
• Corticosteroid and LABA Inhalers Dulera HAWKI only #P-23325 
• Daytrana #P-2322 
• Embeda (morphine sulfate and naltrexone hydrochloride) #P-23270 
• Erbitux (cetuximab) #P-23191 
•  GLP-1 Agonists (Byetta, Bydureon, and Victoza) #P-23150 
• Growth Hormone #P-23164 
• Hepatitis C Drug Therapies #P-23159 
• Hereditary Angioedema Therapies #P-23348 
• * IV and SC Immune Globulins (IVIG) #P-23160 
• *Increlex (mecasermin) #P-23162 
• Infergen (interferon alphacon-1) #P-23161 
• Kalydeco (ivacaftor) #P-23334 
• Kuvan (sapropterin dihydrochloride) #P-2387 
• Long-Acting Opioids #P-23229 
• Neuromuscular Blocking Agents #P-23168 
• Nonsedating Antihistamines #P-23302  
• Nuvigil #M-23157 
• Oleptro (trazodone hydrochloride extended-release) #P-23276 
• Oral Erectile Dysfunction (ED) Medications #M-23153 
• Oral Fentanyl Agents #P-23228 
• Parkinsons Disease (RequipXL & Mirapex ER) P-23264 
• Pradaxa (dabigatran etexilate) #P-23283 
• Promacta (eltrombopag) #P23251 
• Proton Pump Inhibitors (PPIs) #M-23104 
• Provigil #M-23157 
• Psychostimulants (hawk-i) #M-23213 - Iowa only
• Sedative Hypnotics #P-2365 
• *Synagis (palivizumab) Enrollment Form #P-23155 
• Testosterone Topical and Buccal #P-23349 
• Tetracyclines #P-23310 
• Topical Retinoids/Retinoid-Like Agents #M-23135 
• Treximet (sumatriptan/naproxen) #P-23203 
• Tykerb^® (lapatinib) #P-2363 
• Uloric (febuxostat) #P-23255 
• Vectibix (panitumumab) #P-23190 
• Wellbutrin SR and Wellbutrin XL (bupropion extended-release) #M-23139 
• Xenazine (tetrabenazine) #P-23208 
• Xarelto (rivaroxaban) #P-23331 
• *Xolair (omalizumab) #P-23152 
• Zyclara (imiquimod cream 3.75%) #P-23272 

*View the medical policies associated with these drugs.

Prior Approval Medical Forms 

• Prior Approval Form (To determine when to complete this form, visit Authorizations. 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.)
  • Iowa - Medical #P-4602 
  • South Dakota - Medical #N-3614 
  • FEP (Federal Employee Program) Medical/Surgical Prior Approval Form #P-4306 

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 
  • South Dakota - #B3402 
• Provider Post-Service Appeal Form (second step in claim review process)
  • Iowa - #S-53259 
  • South Dakota - #S-3317 

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 
  • South Dakota - #B-3316 

Referral Forms

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

• Wellmark Health Plan of Iowa Chiropractic Referral Form Only 

Miscellaneous Forms 

• Authorization to Use or Disclose Protected Health Information 
  • Individual Authorization
    • Iowa - #S-53258 
    • South Dakota - #S-3315 

  • Designation of Authorized Representative

    • Iowa - #S-53257 
    • South Dakota - #S-3316 
• Back-up Physician Change Form - Iowa only
• Change Form (address, Tax ID; a completed W-9 Form  must accompany any Tax ID change)
• Electronic Claim Payment Form 
• Member Specialty Pharmacy Enrollment Forms
  • Caremark Specialty Pharmacy Enrollment Form 
  • Hy-Vee Pharmacy Solutions (HPS) Specialty Pharmacy Enrollment Form