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 2021 Well Wisconsin Program. The form must be submitted by October 8, 2021.

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
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

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