WYhealth...Get Plugged In!

The Care Management Program with Wyoming Medicaid

Forms and Policies

Downloadable Forms
For best results,
use a Chrome or Firefox browser.

Internet Explorer Users Please Note: You may get the following sign in screen when trying to download certain forms. Please click on CANCEL until the form loads.

If you would like to be faxed or emailed Word copies of these documents, contact 888-545-1710.

Provider Care Management Referral Form

Psychiatric Care Criteria:

Acute Inpatient Psychiatric Hospitalization Criteria

Psychiatric Residential Treatment Facilities Criteria

Medical Care Criteria:

Bone Marrow/Stem Cell and Organ Transplant Services

EPSDT Check List

Nursing Facility Extraordinary Care Criteria

Physical Rehabilitation Services

Vagus Nerve Stimulation (VNS) for Epilepsy

Weight Loss Surgery

Behavioral Health Forms For Download:            

Acute CSR Form

Acute Psychiatric Admission Form

Behavioral Health Discharge Form

PRTF Admission Form


PRTF Incident Report Form

Retrospective Form

ICR Forms:

Acute ICR Report Form

SNF Census Report Form

Medical Health Forms For Download:

Rehab Precertification Form

Rehab Continued Stay Form

Retrospective Form

Skilled Nursing Extraordinary Care Admission Form

Skilled Nursing Extraordinary Care CSR

Transplant Prior Authorization Form

Vagus Nerve Stimulator Prior Authorization Form

Weight Loss Prior Authorization Form

WDH Referral Form

Brochures and Posters For Download:

Nurse Line Brochure - English

Nurse Line Brochure - Spanish

Program Overview Brochure for Medicaid Recipients

Program Overview Brochure for Medicaid Providers

Wyoming State Hospital UR Program:

LOCUS Work Sheet

WSH Designated Hospital CSR

WSH Discharge Form


WSH IH Notification

New Authorization Requirements for Advanced Radiology, Cardiology and Radiation Therapy Services:

Click Here for the Provider Letter sent on April 21, 2015

Click Here for the List of Codes requiring authorization

Click Here for an Advanced Radiology and Cardiology authorization form

Click Here for a Radiation Therapy authorization form