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

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 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 pdf.


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 pdf


To enroll your patients in specialty pharmacy programs:

CVS/caremarkEnroll online pdf or call 800-237-2767 

Hy-Vee -  Enroll online pdf or call 877-794-9833

Physical Medicine Form 

Prior Approval Medical Forms 

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.

Referral Forms

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

Skilled Nursing Provider Forms

Miscellaneous Forms 

© Wellmark, Inc. All Rights Reserved.
Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota.
Privacy & Legal