Provider Forms

Interested in becoming a WPS Preferred Provider?

WPS New Provider Assessment Request Form

Provider Updates

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

Corrected Claim Cover Sheet

• Corrected Claim cover sheet

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/ Psychological and Neuropsychological Testing
• Outpatient Behavioral Health Treatment Request Form
• Outpatient Behavioral Health Treatment Request Form - WPS Employee Group
• Outpatient Behavioral Health Treatment Request Form - Instructions

Autism Processes

• Do you need to be certified yet as an autism qualified provider?
  Please download, fill out and return the WPS Professional Staff Update Notification form.
• Has the service level for your patient been determined?
  (Intensive vs. Non-intensive) Please download, fill out and return the
  Autism Spectrum Progress Report form.

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

• Glossary of Health Coverage and Medical Terms
• Utilization Management/Quality Management Program and Procedures