Managed Care Providers

Forms
WPS Individual Health Insurance Application
Wisconsin Health Insurance Policy Change Application
Pre-Authorization Request Form
Wisconsin Physicians Service Electronic Media Claims Agreement
WPS Internet Website User Agreement
Psychological Testing Request Form
Wisconsin Physicians Service ERA Authorization Form
Group Size Questionnaire
Employee Enrollment Application
WPS Internet Website User Agreement
Student Health Insurance Enrollment Form
Group Size Questionnaire
WPS EDI Trading Partner Profile Form
Estimation of Out of Pocket Expenses Form
Wisconsin Student Health Insurance Enrollment Form
Outpatient Behavioral Health Treatment Plan
Medicare Select Enrollment Application
TRICARE for Life EFT Authorization Form
Health Allergy Medication Questionnaire
Employer’s Group Application
Medicare Part D Direct Claim Form
Student Health Insurance Enrollment Form
Medicare Select Enrollment Application
WPS Commercial Electronic Funds Transfer Authorization Agreement
EDI Change of Submitter Form
Wisconsin Individual Major Medical Insurance Application
WPS MedicareRx Plan Individual Enrollment Form
Wisconsin Health Insurance Supplemental Application
Delta Dental of Wisconsin Small Group Application
Dental Wisconsin Enrollment Form
Health Allergy Medication Questionnaire
Student Health Insurance Enrollment Form
Employee’s Self-Funded Plan Enrollment Application
Student Health Insurance Enrollment Form
Medicare Supplement Enrollment Application
WPS Individual Health Plan Application
tricare west region eft
EDI Enrollment Form
Wisconsin Individual Major Medical Health Insurance Application
Student Health Insurance Enrollment Form
Wisconsin Individual Major Medical Health Insurance Application
Credit/Debit Card Payment Authorization Form
Wisconsin Group Health Insurance Application
Wisconsin Individual Major Medical Health Insurance Application
Student Health Insurance Enrollment Form
WPS Health Insurance Pre-Authorization Request Form
EDI Change of Submitter Form
Wisconsin Health Insurance Supplemental Application
Wisconsin Student Health Insurance Enrollment Form
Student Health Insurance Enrollment Form