Iowa
Provider
Forms
Below are printable forms in PDF format available for you to download and print. If you have a supply of paper forms in your office, please compare to the online version to verify your forms are up to date.
To view these documents you will need Adobe Reader.
Choose the icon to download for free. 
To order a larger supply of forms or to order materials not listed on this page, use the Provider Order Form.
Page Contents:
Electronic Claim Forms
Enrollment/Participation Forms
These forms, excluding the W-9 form, can be completed online using Adobe Reader. Then you can print, sign and send to Wellmark for processing.
Member Workers’ Comp/COB Questionnaires
Paper Claim Forms
Pilot on Quality Physical Medicine Forms
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.
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
(These forms can be completed online, but you must print and fax the forms to 1-866-884-4345.)
Prior Approval Medical Forms
Provider Appeal Forms
Radiology Preauthorization Forms
Referral Forms
Miscellaneous Forms
|
