Form Active Employee / Local Employer / State Employer

Health Care Provider Form

Complete this form using results from your most recent health care provider visit to earn credit for the Well Wisconsin Program.

State Maintenance Plan (SMP) by Dean Health Plan

Major Health Systems
  • Marshfield Medical Center
  • St. Vincent Hospital-Hospital Sisters-Third Order of St. Francis
  • Dickinson County Healthcare System
Full Service Areas
  • Florence County
Limited Service Areas
  • Michigan

Benefits and Services FAQs

Program Option
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
Plan Year
  • 2025