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.

Hand writing notes

Plan Designs Quick Comparison

Learn about the key differences between plan designs, such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.

Program Option
  • State Employee and Retiree Health Plan & Supplemental Benefits
Plan Year
  • 2025

Steps to Choosing Your Benefits

Not sure where to start? This page is a step-by-step guide to choosing your benefits.
Plan Year
    2025
Program Option
    Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits

Steps to Choosing Your Benefits

Not sure where to start? This page is a step-by-step guide to choosing your benefits.
Plan Year
    2025
Program Option
    Local Traditional Health Plan (PO12) & Supplemental Benefits

Steps to Choosing Your Benefits

Not sure where to start? This page is a step-by-step guide to choosing your benefits.
Plan Year
    2025
Program Option
    Local High Deductible Health Plan (PO17) & Supplemental Benefits

Steps to Choosing Your Benefits

Not sure where to start? This page is a step-by-step guide to choosing your benefits.
Plan Year
    2025
Program Option
    Local Health Plan (PO16) & Supplemental Benefits

Steps to Choosing Your Benefits

Not sure where to start? This page is a step-by-step guide to choosing your benefits.
Plan Year
    2025
Program Option
    Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits

Steps to Choosing Your Benefits

Not sure where to start? This page is a step-by-step guide to choosing your benefits.
Plan Year
    2025
Program Option
    Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits

Steps to Choosing Your Benefits

Not sure where to start? This page is a step-by-step guide to choosing your benefits.
Plan Year
    2025
Program Option
    Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits