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

State Maintenance Plan (SMP) by Dean Health Plan for Locals

Major Health Systems
  • Aspirus Health
  • Ascension Wisconsin
  • Aurora Health Care
  • Essentia Health
  • Marshfield Clinic
  • Northlakes Community Clinics
  • St. Luke's (Aspirus Health)
Full Service Areas
  • Adams County
  • Ashland County
  • Barron County
  • Bayfield County
  • Buffalo County
  • Burnett County
  • Clark County
  • Columbia County
  • Douglas County
  • Dunn County
  • Florence County
  • Forest County
  • Grant County
  • Green County
  • Iowa County
  • Iron County
  • Jefferson County
  • Juneau County
  • Lafayette County
  • Langlade County
  • Lincoln County
  • Marathon County
  • Marquette County
  • Menominee County
  • Oneida County
  • Polk County
  • Portage County
  • Price County
  • Richland County
  • Rock County
  • Rusk County
  • Sauk County
  • Sawyer County
  • St. Croix County
  • Taylor County
  • Vilas County
  • Walworth County
  • Washburn County
  • Wood County
Limited Service Areas
  • Michigan
  • Minnesota