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.

HSA Eligible Expenses

An eligible expense is a health care service, treatment, or item the IRS states can be paid for without taxes. Eligible expenses can be incurred by you, your spouse, or qualified dependents. The Health Savings Account (HSA) can only be used to pay for eligible medical expenses incurred after your HSA was established.

Program Option
  • State Employee and Retiree Health Plan & Supplemental Benefits
Plan Year
  • 2024