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

Nursing Facility Extraordinary Care Criteria

Physical Rehabilitation Services

Vagus Nerve Stimulation (VNS) for Epilepsy

Weight Loss Surgery



Behavioral Health Forms For Download:            

Acute Psychiatric Admission Form

Acute Psychiatric Admission Title 25 Form

Acute CSR Form

Behavioral Health Discharge Form

PRTF Admission Form

PRTF CSR Form

PRTF Incident Report Form

Retrospective 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 CSR

WSH IH Notification

 
 
Website Builder