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Serving Wyoming Medicaid Providers


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Wyoming Medicaid - Claim Forms


NPI Updated Forms    


Dental Claim (489 K)


UB-04 Claim (1.39MB)


CMS-1500 (02-12)




Wyoming Medicaid - Enrollment/Agreement Forms

  Provider Enrollment Application
  Letter of Attestation
  Taxpayer ID# Request / WOLFS-109a Form - for New Providers Only
  WOLFS-109b Form - for Updates to existing Provider Information


Wyoming Medicaid - EDI Applications


Wyoming Medicaid Clearinghouse Authorizations Form - This form is to be completed by providers wishing to authorize/join a clearinghouse or billing agent.


Wyoming Medicaid Clearinghouse Applications - This form is for Clearinghouses, Software Vendors or Billing Agents who need to enroll with Wyoming Medicaid to provider electronic services to providers. Electronic services include web portal access, submission of transactions, and receiving 835 files. This form can also be used to make changes to an already enrolled trading partner.


EDI Enrollment Application and Agreement - Providers that need to enroll with Wyoming Medicaid for Electronic services, including web portal access, submission of transactions and receiving 835 files need to complete this form. It can also be used to make changes to an already enrolled trading partner.


Wyoming Medicaid - Extraordinary Care


Nursing Facility Extraordinary Care (208K)


Wyoming Medicaid - Miscellaneous Forms


Abortion Certification (5 K)
Adjustment/Void Form (118 K) Instructions(24K)
Attachment Control Document (36 K)
Attestation For Admission Date Form
Certification of Disproportionate Share Form (8 K)
CAP Limit Waiver Request Form (11KB)
Crippling Malocclusion Scoring Sheet
Crippling Malocclusion Referral Form Updated
Dental Provider Client Acceptance Form Updated
DME Mileage Verification (22K)Updated
Electric Breast Pump CMN (22K)
Wyoming Medicaid Client Death Report Form (15KB)
Home Health Exemption Letter (95KB)
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 Consent Form
LT-101 Consent Form Letter
LT-101 Referral Form
LT-101 Referral Process Physicians Assistants and Nurse Practicioners
LT-101 Referral Process Facilites and Hospitals

Medical Necessity (7 K)
Order Form (45K)
Orthodontic Parent Handout
Parenteral Nutrition Necessity (10 K)
Prior Authorization Request - Non-DME (12 KB)
Prior Authorization Non-DME - Instructions(23 K)
SCM-OS Referral Form
Sterilization Consent (16 K)
Remittance Advice Request Form
Report of Suspected Abuse
Third Party Resources Information (14K)
Wheelchair Necessity (13 K)
WY Department of Health Swing Bed Exemption (96KB)
WY PASRR Informed Consent 02/18/2010 (36K)


Wyoming Medicaid - 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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