Printer-Friendly Page

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 Transaction Registration/Enrollment Forms 
• Enrollment/Participation Forms
  • Provider Change Forms
• Member Related Forms and Questionnaires
  • My Prescription for You 
  • Authorization to Use or Disclose Personal Health Information 
  • Personal Representative Appointment
• Paper Claim Forms 
• Pharmacy Forms
  • Pharmacy Exception Request for Non-Formulary Medications 
  • Prior Authorization Pharmacy Forms 
  • Member Specialty Pharmacy Enrollment Forms 
• Physical Medicine Forms 
• Prior Approval Medical Forms 
• Provider Claim Review Forms 
• Referral Forms 
• Miscellaneous Forms 

Electronic Claim Transaction Registration/Enrollment Forms 

• Electronic Transaction Registration Packet #S-53260  
• Create and Submit Claims Submitter Number Registration Form for Wellmark Professional Claims #K-2307  
• Electronic Fund Transfers (EFT) & Electronic Remittance Advice (ERA)

  Be sure to contact your financial institution(s) to make certain they are aware of the CAQH CORE (Council for Affordable Quality Healthcare, Committee on Operating Rules for Information Exchange) EFT and ERA operating rules. The appropriate arrangements will need to be made between you and your financial institution to accommodate the delivery of the CORE required minimum CCD+ (Cash Concentration or Disbursement including an addenda record) Data Elements necessary for reassociation of the EFT payment with the ERA. CAQH CORE has developed a sample letter for providers to utilize when reaching out to their financial institutions. Access http://caqh.org/CORE_EFT_ERA.php for additional information pertaining to reassociation.

• Electronic Fund Transfer (EFT) Form 
  • If you have questions regarding a missing or invalid EFT payment, submit an inquiry.
• Electronic Remittance Advice (ERA)/835 Enrollment Form  
  • If you have questions regarding a missing or invalid ERA, submit an inquiry.

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
• Provider Change Forms
  • Back-up Physician Change Form - Iowa only
  • Change Form (address, Tax ID; a completed W-9 Form  must accompany any Tax ID change)

Member Related Forms and 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 
• 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 
• Personal Representative Appointment
  • Iowa - #C-5674 
  • South Dakota - #C-3617 

Paper Claim Forms

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

Pharmacy Forms

• 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  
• 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  
  • Anti Constipation (Amitiza, Linzess, Relistor) #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 

  • *Biologic and Immunomodulatory Drug Therapy #P-23351 
  • Brand SSRIs and SNRIs (Cymbalta, Lexapro, Luvox CR, Pexeva, Pristiq, Viibryd) #P-23237  
  • Celebrex® (celecoxib) #M-2382  
  • Contraceptives (Oral, Transdermal, Intravaginal Ring) #M-23155 
  • Corticosteroid and LABA Inhalers Dulera HAWKI only #P-23325 
  • Daytrana #P-2322 
  • Embeda (morphine sulfate and naltrexone hydrochloride) #P-23270 
  • GLP-1 Agonists (Byetta, Bydureon, and Victoza) #P-23150 
  • Growth Hormone #P-23164 
  • Hepatitis C Drug Therapies #P-23159 
  • Hereditary Angioedema Therapies #P-23348 
  • H.P. Acthar (repository corticotropin) #P-23355  
  • * Immune Globulin Therapy (IVIg and SCIg) #P-23160 
  • *Increlex (mecasermin) #P-23162 
  • Infergen (interferon alphacon-1) #P-23161 
  • Inhaled Corticosteroids #P-23324 
  • 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 
  • 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 
  • *Xolair (omalizumab) #P-23152 
  • Zyclara (imiquimod cream 3.75%) #P-23272 

*View the medical policies associated with these drugs.

• Member Specialty Pharmacy Enrollment Forms
  • Caremark Specialty Pharmacy Enrollment Form 
  • Hy-Vee Pharmacy Solutions (HPS) Specialty Pharmacy Enrollment Form 

Physical Medicine Form 

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

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.

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