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.

Some Out-Of-State Coverage

Medical Associates Health Plan

Major Health Systems
  • Medical Associates Clinic
  • Mercy Medical Center - Dubuque
  • Crossing Rivers Health
  • Grant Regional Health Center
  • Southwest Health Center
Full Service Areas
  • Crawford County
  • Grant County
  • Iowa County
  • Lafayette County
Limited Service Areas
  • Iowa
  • Illinois

Health Insurance Employer Forms

Use the forms on this page to administer the Group Health Insurance program. If you are not finding what you need, go to the Publications page to search through all publications.

ET-4110
Form Retiree

Health Insurance - Integrated with Medicare

The following information is for those retirees who are transitioning into Medicare under the State or the Wisconsin Public Employers Group Health Insurance Programs.