Forms & Documents for Members

General Information

• Changes in Coverage Status
• How to File Claims
• Understanding Your Explanation of Benefits
• WPS Preferred Drugs Guide
• EyeMed Vision Discount Program - Tip Sheet
• HealthSense Rewards Tip Sheet
  
  
• Individual Policy Change Application

Estimate Out-of-Pocket Expenses

• Information Regarding the Estimation of Out-of-Pocket Expenses Form (WI Act 146)
• Estimation of Out-of-Pocket Expenses Form - Facility Services
  (Example: Inpatient/outpatient hospital)
  
• Estimation of Out-of-Pocket Expenses Form - Professional Service
  (Example: Doctor services/lab work)

WPS Medicare Prescription Drug Plan

• Prescription Mail Order Form
• Health, Allergy & Medication Questionnaire

Preauthorization Forms

• Inpatient Pre-Certification Guidelines
• Outpatient Pre-Authorization Guidelines
• Medical Preauthorization Request Form
• WPS Drug Preauthorization List

Pay By Credit/Debit Card

• Credit/Debit Card Authorization Form

HIPAA Forms and Documents

• More Information on HIPAA
• Notice of Privacy Practices
• Appeals/Grievance Authorized Representative Form
• Authorization for WPS to Disclose Health Information
• General Authorization to Use and Disclose Health Information
• Request to Access PHI
• Request to Amend PHI

Fraud Forms

• Special Investigations Unit

Web Tools

• Member Web Tools
• Visit our How to Register area to help with online registration to use the WPS website