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This web page serves as a central repository for Wyoming Medicaid Forms. Below are four (4) content blocks. Each block houses an array of forms aligned by Claim Types: CMS 1500, Dental, and Institutional/UB. In addition, the last content block offers forms aligned to All Provider types.

Once a block is selected, the selected block will open and display all forms associated with that specific content block.

CMS 1500 forms

Abortion Certification Form

DME Mileage Verification Form

Hysterectomy Acknowledgment of Consent Form

Hysterectomy Acknowledgment of Consent Form (Spanish)

K0108/E1399 Crossover Claim Form

LTC Waiver Plan of Care (C-501A)

Order vs Delivery Date Billing Attestation Form

Sterilization Consent Form

Sterilization Consent Form (Spanish)

Travel Request Form

Dental forms

Dental Provider Member Acceptance Form

Non Medicaid Member Primary Dental Insurance Attestation Form

Medicaid Member Primary Dental Insurance Attestation Form

Institutional / UB forms

Attestation for Admission Date

Hospice Benefit Election Form

Hospice Benefit Revocation Form

Hospice Exemption Form

Hospice NH Room and Board Request Form

Medicaid Member Death Report Form

Title 25 Certification Form

Title 25 Provider Checklist Coversheet

All Provider forms

Attachment Coversheet

Adjustment Void Form

Documentation of Medical Necessity Form

First Level Grievance and Appeal Form

Second Level Grievance and Appeal Form

Previous Attempts to Bill Letter Form

Provider Inquiry Form

Third Party Resources Information Sheet