Forms

Interested in becoming a WPS Preferred Provider?

• WPS New Provider Assessment Request FormSuClaim

Provider Updates

• Add Individual Provider Form
• Update Individual Provider Form
• Add New Clinic/Facility Form
• Update Clinic/Facility Form
• Termination of Clinic/Facility Form

Preauthorization Forms

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

Outpatient Behavioral Health Treatment Plans

• Certification Request/Initial Outpatient Treatment
• Certification Request/Follow-Up Outpatient Treatment

HIPAA Forms and Documents

This provides a collection of HIPAA forms and documents, particularly those regarding PHI (Personal Health Information).

• 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

Additional Information

• Utilization Management/Quality Management Program and Procedures
• Common Claim Codes Explained (Member Help Area)