Well Wisconsin Health Care Provider Form

The health care provider form is used for participants who choose to submit results obtained by a physician.

Completed form is due on or before October 11, 2024 by 11:59pm CST

Before you submit your form, make sure you:

• Step 1: Print clearly and complete all fields on the top of the form.  Be sure to provide a valid email address to receive a confirmation email if you would like to receive notification your form was received.
• Step 2: Ensure YOU have signed your form.  Without your signature, this form will not be accepted.

To submit your form, select Choose File to load your document, then select Submit.