Independent Care Health Plan
1555 N. RiverCenter Dr., Suite 202A
Milwaukee, WI 53212
1-800-777-4376 (TTY 1-800-947-3529)

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Forms & Publications

You can view or print various iCare forms and publications. You can access the provider directory, newsletters, brochures, and more. Click on the links below to access these items (please note that some items may take time to download).

Member Publications

iCare Medicaid/SSI Plan

Member Handbook

Provider Directory

iCare Brochure

Emergency Room Brochure

iCare Medicare Plan

Member Handbook/
Provider Directory

Benefits & Services Guide

Evidence of Coverage

LIS Rider

Summary of Benefits

Abridged Drug Formulary

Comprehensive Drug Formulary

iCare Medicare Plan Enrollment Form

Coverage Determination Request Form

CMS Appointment of Representative Form

Providers

Provider Manual

EOP Sample

Provider Newsletters

General Prior Authorization form

Home Health/Personal Care Worker Prior Authorization Form

Therapy Prior Authorization Form

CMS Model Coverage Determination Request Form

Physician Referral Form

Other Publications

Report to the Community

Member Newsletters

Privacy Statement

Viewing some these publications requires Adobe’s Acrobat Reader software, a free utility, please click on the button to the right and follow the directions to download.

Last updated 11/06/2006

Forms & Publications

Providers

Provider Manual EOP Sample Provider Newsletters General Prior Authorization form Home Health/Personal Care Worker Prior Authorization Form Therapy Prior Authorization Form CMS Model Coverage Determination Request Form

Provider Manual

EOP Sample

Provider Newsletters

General Prior Authorization form

Home Health/Personal Care Worker Prior Authorization Form

Therapy Prior Authorization Form

CMS Model Coverage Determination Request Form