Forms

Just a finger-click away.

Select the topic area to go directly to that section.

• Designation of an insurance representative
• Authorization of a third party
• Authorization to a provider
• Participant revocation of authorization
• Participant right to access protected health information
• Request for alternative communications

Not sure which HIPAA form you need? Click here for a listing with form summaries.

• Care Management Enrollment
• Find a Doctor/Dentist (or other medical provider/facility)
• Media Request
• Website feedback
• Change your personal information **
• Change your beneficiary (Life) **

** Please use your Subscriber Number in place of the requested Social Security Number!!!  

Not finding what you're looking for? Check under the specific plan. 

Provider

Treatment plans

• Outpatient mental health treatment plan
• Psychological/neuropsychological testing request for authorization

HIPAA authorization for providers

Update your network profile

Complete and submit by mail or fax: 

• Organization Provider Update (pdf) – For organizations with 4 or less service locations and 20 or fewer practitioners.
• Individual Provider Update (pdf) – For individual practitioners.

Attention: Provider Services Manager, via fax 608.276.9119 or mail to WEA Trust, P.O. Box 7338, Madison, WI 53707-7338. 

Join our network

We are eager to work with you. Complete these 2 forms—

• WEA Provider Network Application (fillable pdf) and
• W-9 Tax Form (pdf)

And submit them Attention: Provider Services Manager via 1 of the methods below:

fax: 608.276.9119

email: Provider Services Manager

mail: WEA Trust, P.O. Box 7338, Madison, WI 53707-7338

• Health Insurance Group Application

• Caremark Mail Order Delivery Service
• Caremark Prescription Reimbursement Claim
• Caremark Foreign Claim Form (Reimbursement)
• Online Prescription Drug search—NON-State plans only

• Short Term Disability Claim Form
• Short Term Disability Supplemental Medical Report
• Short Term Disability Supplemental Claimant's Report
  
  
• Long Term Disability Claim Form
• Long Term Disability Supplemental Medical Report
• Long Term Disability Supplemental Claimant's Report
  
  
• Consent for Disclosure of Confidential Information

• Adult child – health questionnaire
• Adult child – dental questionnaire

• Life Beneficiary form
• Change Beneficiary online
• Consent for Disclosure of Confidential Information

• Online enrollment
• Change your personal information **
• Change your beneficiary (Life) **
• Online Enrollment Review (Employers)

** Please use your Subscriber Number in place of the requested Social Security Number!!! **

• Caremark Mail Order Delivery Service
• Caremark Prescription Reimbursement Claim
• Caremark Foreign Claim Form (Reimbursement)
• Online Prescription Drug search—NON-State plans only

• Direct Deposit Form
• Employer Contribution Report
• Employer Information Form
• Employer Information Form (Excel)
• Group Enrollment Form
• Letter of Medical Necessity
• Participant Enrollment and Change Form
• Reimbursement Claims Form
• Suspension Election Form