Wisconsin Customer Forms and Resources

• Medicaid and the Children's Health Insurance Program (CHIP)
• Medicaid y el Programa de Seguro Médico para Niños (CHIP)
• Members Rights and Responsibilities
• Women’s Health and Cancer Rights Act and Newborns’ and Mothers’ Health Protection Act Notice
• Aviso de la Ley de Derechos sobre la Salud y el Cáncer de la Mujer y de la Ley de Protección de la Salud de los Recién Nacidos y las Madres
• Your Rights and Protections Against Surprise Medical Bills

• Shingles Immunization form for Medicare Supplement Base Plan Customers



• Customer Account Flyer
• Customer Portal Tip Sheet
• Registering for Your Customer Account tip sheet
• Summary of Benefits tip sheet
• View Your EOB and Summary EOB tip sheet
• How to View Claims and EOBs
• How to View Authorizations
• Consumerism tip sheet
• Hoja de consejos para el consumismo
• EyeMed Vision Care Discount program tip sheet
• Glossary of Health Coverage and Medical Terms
• Understanding Your Explanation of Benefits

Under Sec. 111 in the H.R. 133, the Consolidated Appropriation Act, health plans are required to send patients an Advance Explanation of Benefits (AEOB) after receiving a good faith estimate notification from a provider or facility that an individual is scheduled to receive an item or service. In addition, 2009 Wisconsin Act 146 requires hospitals, insurance plans, and health care providers to disclose information about the cost and quality of health care services. Complete the request form to obtain an estimate of out-of-pocket expenses for the member.

• Information Regarding the Estimation of Out-of-Pocket Expenses Form (WI Act 146)
• Estimate for Out-of-Pocket Costs

• Prescription Mail Order Form

• WPS Medical Prior Authorization
  For Aetna Signature Administrators Participating doctors and hospitals please contact American Health Holdings at 866-726-6584 for prior authorization.
• Helpful Tips for Prior Authorization
• Prior Authorization Request Form
• WPS Drug Prior Authorization List
• For pharmacy drugs, log on through your preferred ePA Portal (preferred)
  To learn how to get started, visit bit.ly/express-scripts-easy-epa or use the ePA feature through your electronic health record service, if available
  Phone: 800-475-1954
  Fax: 833-933-2367
• For medical specialty drugs, log onto https://www.evicore.com/provider
  Phone: 800-475-1954
  Fax: 833-933-2367
• Medical oncology and radiation oncology requests for authorization(s) will be reviewed by eviCore Healthcare. To request an authorization(s):
  Log onto https://www.evicore.com/provider (preferred)
  Phone: 800-475-1954
  Fax: 800-540-2406
• How to View Authorizations

• See payment options

This provides a collection of HIPAA forms and documents, particularly those regarding personal health information (PHI).

• More Information on HIPAA
• Notice of Privacy Practices
• Authorized Representative Form for Grievance/Appeal
• Authorization for WPS to Disclose Health Information
• Confidential Communications
• Consent to Unsecure Email Communication
• Request to Access PHI
• Request to Amend PHI
• Instructions for Completing the Customer Authorization Form
• Privacy Complaint Form
• Interoperability Customer Consent to Share Data Form

Use this personal health record form to record and maintain a history of your health information. Keep your personal health summary handy, and bring it to your health care office visits so you can talk with your health care provider about preventive care.

• Download a blank personal health summary form
• Customize your own at MedlinePlus.gov