Below are the current versions of most common provider forms. Because these documents are subject to change, please do not stockpile printed versions for your office. Instead, please access these forms as needed from this page, printing only when absolutely necessary.
Electronic Claim Transaction Registration/Enrollment Forms
Member Related Forms and Questionnaires
- Member Coordination of Benefits Questionnaire
Personal Representative Appointment
Network Participation Forms
All forms regarding network participation are available at our Credentialing and Contracting page. On our page, you will also find the Credentialing Submission Tracker where you are able to track the status of your applications, recredentialing submissions, and change requests.
Paper Claim Forms
Pharmacy exception requests for non-formulary medications
If your patient needs a non-formulary drug, he or she may ask for an exception request. This process may allow coverage for those drugs not included in his or her drug list. To review this process, please visit the CVS/caremark Prior Authorization page .
Your patient also has the option of contracting Wellmark Customer Service at the number printed on the back of his or her ID card.
Pharmacy Prior Authorization Process
Please start by referring to the Pharmacy Prior Authorization page. There you will find an alphabetical listing of medications with Wellmark's corresponding pharmacy policy. If a medication is not listed, Wellmark does not maintain a pharmacy policy for it.
To download a global prior authorization form, please visit the CVS/caremark Prior Authorization page .
To enroll your patients in specialty pharmacy programs:
CVS/caremark - Enroll online or call 800-237-2767
Hy-Vee - Enroll online or call 877-794-9833
Physical Medicine Form
Prior Approval Medical Forms
- Prior Approval Form (To determine when to complete this form, visit Important Authorization Terms. 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.)
Provider Claim Review Forms
For guidance, please visit the Appeals and Inquiries page.
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.
To submit out of network and referral requests, use the online Utilization management tool. Please refer to the Quick Start Guide .
Skilled Nursing Provider Forms
I need secure access to:
Tools and resources related to:
- Utilization Management
Take me there.
E-credentialing Central to access these tools:
- Application Tool (coming soon)
- Change Request Tool
- Recredentialing Tool
- Provider Directory Update Tool (coming soon)
- Submission Status Tracker
- Submission History Tool
- View my Organization
- Manage my Users
Take me there.