			Home \| Contact Wellmark \| Work @ Wellmark \|
			Members \| Employers \| Providers \| Brokers \| About Wellmark

South Dakota Provider Forms

Forms for Wellmark Blue Cross and Blue Shield of South Dakota providers include the following forms.

To view these documents you will need Adobe Reader.
Choose the icon to download for free.

Page Contents:

Electronic Claims Forms
Enrollment/Participation Forms
Member Workers’ Comp/COB Questionnaires
Paper Claim Forms
Physical Medicine Pilot on Quality Forms
Prior Authorization Pharmacy Forms
Prior Approval Medical Forms
Provider Appeal Forms
Radiology Preauthorization Forms
Referral Forms
Miscellaneous Forms

Electronic Claims 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

Physical Medicine Pilot on Quality Forms

Initial Chiropractic Care Plan - #S-2306 (PDF for completion and faxing)
Initial Chiropractic Care Plan (BlueConnection tool for online submission —must be a registered user to access)

Use the Extension of Chiropractic Care Plan to request additional services or visits beyond what was outlined in the Initial Chiropractic Care Plan, or to report a change in a patient’s condition or diagnosis.

Extension of Chiropractic Care Plan - #S-2307 (PDF for completion and faxing)
Extension of Chiropractic Care Plan (BlueConnection tool for online submission —must be a registered user to access)

CoQ Physical Medicine Discharge/Outcomes of Care - #S-2313

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

Cognitive Rehabilitation Treatment Plan - #P-2316
Outpatient Treatment Report - #C-5364
Physical Medicine Treatment Plan
Prior Approval Form - Medical - #N-3614 (To determine when to complete this form, visit Prior Approval.)
Physician Certification for Morbid Obesity Surgery - #P-3317
PT or OT Evaluation Form - #S-2308

Provider Appeal Forms

Overpayment Recovery Appeal Form for CMS-1500 Billers

Radiology Preauthorization Forms

Radiology Preauthorization Fax Form
Oncologic PET Scan Fax Form
For Post-Service Appeals — Provider Inquiry Form #B3402

Referral Forms

Disease Management and Pregnancy Program Referral Form #P-23100

Miscellaneous Forms

Accommodative Intraocular Lens Implant Waiver
Authorization to Use or Disclose Protected Health Information: The authorization form for providers to use when releasing clinical information to Wellmark will be available shortly. Please check this site at a later date.
Authorized Representative Appointment and Authorization for Release of Information #C-3617(U)
Caremark Specialty Pharmacy Enrollment Form
Change Form (address, Tax ID; a completed W-9 Form must accompany any Tax ID change)
Designation of Authorized Representative
Hospital Privileges Update Form
Individual Authorization
Preventive Care Tollkit Online Order Form
Provider Forms Order Form - #B-3001
Provider Inquiry Form - #B3402 (You may complete this form online, but must print it and mail it to Wellmark.)
Synagis® Enrollment Form
W-9 Form
2008 Wellmark Wall Calendars

Copyright© 2008 Wellmark, Inc. All Rights Reserved.
Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross®, Blue Shield®, and the Cross® and Shield® symbols are registered marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.