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Serving Wyoming EqualityCare Providers

 

 

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Wyoming EqualityCare - Claim Forms

 

Dental Claim (281 K)
CMS-1500 (12-90) Claim (22 K)

 

UB-92 Claim (18 K)


 

NPI Updated Forms

 

 

 

Dental Claim (489 K)
CMS-1500 (08-/05) (137 K)

 

UB-04 Claim (26K)
 

 

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

 

Wyoming EqualityCare - Extraordinary Care

 

Nursing Facility Extraordinary Care (290K)

 

Wyoming EqualityCare - Miscellaneous Forms

 

Home Health Letter (333K)
PHN Billing-Wynette (30K)
HH Billing-Wynette (31K)
Abortion Certification (5 K)
Attachment Control Document (36 K)
Claim Request (23 K)
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)

Medical Necessity (7 K)
LT-MR-105 for ICF-MR (67 K)
Parenteral Nutrition Necessity (10 K)
Prior Authorization Request (12 K)
Service Care Plan (10 K)
Sterilization Consent (16 K)
Suspected Abuse (22 K)
Third Party Resources Information (14K)
Void/Adjustment (118 K)
Wheelchair Necessity (13 K)

 

Wyoming EqualityCare - Pharmacy Prior Authorization Program

 

Brand Name Drug Request Form (22K)
Second Request for Patient Exemption from Prior Authorization for Anti-Epileptics Form (21K)
Second Request for Patient Exemption from Prior Authorization Criteria Form (23 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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