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Notice of Privacy Practices

Program Option

Local Deductible Health Plan (PO14) & Supplemental Benefits
Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
Local Health Plan (PO16) & Supplemental Benefits
Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
Local High Deductible Health Plan (PO17) & Supplemental Benefits
Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
Local Traditional Health Plan (PO12) & Supplemental Benefits
Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
State Employee and Retiree Health Plan & Supplemental Benefits

ET-8945

Form Other Benefit Recipient

Vendor Privacy Incident Report

Use this form to report any possible or confirmed breaches of protected health information (PHI) or personally identifiable information (PII).

HIPAA: Privacy, Electronic Transactions Standards and Security

Program Option

Local Annuitant Health Program (LAHP)
Local Deductible Health Plan (PO14) & Supplemental Benefits
Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
Local Health Plan (PO16) & Supplemental Benefits
Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
Local High Deductible Health Plan (PO17) & Supplemental Benefits
Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
Local Traditional Health Plan (PO12) & Supplemental Benefits
Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
State Employee and Retiree Health Plan & Supplemental Benefits

Data Analytics and Insights (DAISI) is a data warehouse and analytics tool administered by Merative. All the organizations that supply health and wellness products and services as part of the Group Health Insurance Program put data into DAISI through a secure file transfer process. DAISI organizes and protects this data and has tools to help make sense of the data.

Mental Health Resources

Mental health is just as important as physical health when it comes to your overall well-being. Learn about mental health resources available through the Group Health Insurance Program and Employee Assistance Programs.

ET-7422

Manual Other Benefit Recipient

Supplemental Insurance Plans Guidelines

This document, “Supplemental Insurance Plan Guidelines,” or Guidelines, serves as a resource for insurers interested in offering the State of Wisconsin employees supplemental insurance plans.

State and Federal Notifications

Program Option

Local Annuitant Health Program (LAHP)
Local Deductible Health Plan (PO14) & Supplemental Benefits
Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
Local Health Plan (PO16) & Supplemental Benefits
Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
Local High Deductible Health Plan (PO17) & Supplemental Benefits
Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
Local Traditional Health Plan (PO12) & Supplemental Benefits
Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
State Employee and Retiree Health Plan & Supplemental Benefits

Flyer Active Employee / Retiree

It’s Your Health: Diabetes

Participating in the Well Wisconsin diabetes condition management program lowers your diabetes-related prescription copays.

Well Wisconsin for Members

The Well Wisconsin program, administered by WebMD, provides tools and resources to help participants set health and well-being goals, track progress, stay motivated, and earn incentives.

Program Option

Local Annuitant Health Program (LAHP)
Local Deductible Health Plan (PO14) & Supplemental Benefits
Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
Local Health Plan (PO16) & Supplemental Benefits
Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
Local High Deductible Health Plan (PO17) & Supplemental Benefits
Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
Local Traditional Health Plan (PO12) & Supplemental Benefits
Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
State Employee and Retiree Health Plan & Supplemental Benefits

ET-7414

Form Active Employee / Retiree / Other Benefit Recipient

Authorization to Disclose Medical Information

This form gives ETF and entities that perform contracted services for ETF permission to release your designated medical information to a person or entity specified by you.