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Wyoming EqualityCare - Claim Forms

 

NPI Updated Forms    

 

Dental Claim (489 K)

 

UB-04 Claim (1.39MB)

 

CMS-1500 (08-/05) (137 K)

 

 

 

Wyoming EqualityCare - Enrollment/Agreement Forms

  Provider Enrollment Application
  EDI Enrollment Application / Update Request Form
  Taxpayer ID# Request / WOLFS-109a Form - for New Providers Only
  WOLFS-109b Form - for Upates to existing Provider Information
  EDI Enrollment Instructions for Clearinghouses and Software Vendors
  EDI Enrollment for Clearinghouses and Software Vendors
  EDI Agreement for Clearing houses and Software Vendors

 

Wyoming EqualityCare - Extraordinary Care

 

Nursing Facility Extraordinary Care (290K)

 

Wyoming EqualityCare - Miscellaneous Forms

 

Abortion Certification (5 K)
Adjustment/Void Form (118 K) Instructions(24K)
Attachment Control Document (36 K)
CAP Limit Waiver Request Form (28K)
DME Mileage Verification (22K)
Electric Breast Pump CMN (22K)
HH Billing-Wynette (31K)
Home Health Letter (333K)
Hysterectomy Consent (6 K)
LTC Waiver Plan of Care C-501A (24 K)
LTC/HCBS Waiver Plan of Care C-501B (23K)
LTC Assisted Living Waiver Plan of Care C-501C (22K)
LTC Waiver Plan of Care - self-directed (89 K)
LT-101 for LTC Necessity (18 K)

LT-MR-104 for ICF-MR (72 K)
LT-MR-105 for ICF-MR (67 K)
Medical Necessity (7 K)
Order Form (45K)
Parenteral Nutrition Necessity (10 K)
PHN Billing-Wynette (30K)
Prior Authorization Request - DME (39 K)
Prior Authorization Request - Non-DME (28 K)
Prior Authorization Non-DME - Instructions(23 K)
Service Care Plan (10 K)
Sterilization Consent (16 K)
Suspected Abuse (22 K)
Third Party Resources Information (14K)
Wheelchair Necessity (13 K)

 

 

Wyoming EqualityCare - Well Child Visit Forms

 

4 Weeks (36 K)
2 Months (36 K)
4 Months (36 K)
6 Months (35 K)

9 Months (36 K)
1 Year (35 K)
15 Months (35 K)
18 Months (35 K)

2 Years (36 K)
3-4 Years (36 K)
5 Years (36 K)
6-10 Years (42 K)

11-14 Years (42 K)
15-17 years (42 K)
18-20 Years (41 K)
 

 

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