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Member Materials and Forms

Thank you for being a WellCare member. On this page, you will be able to quickly find the member materials and forms you may see or need as a member of our plan.
Member Communications

Electronic Funds Transferpdf

WellCare Direct Member Reimbursementpdf

 

Authorization Forms

Appointment of Representativepdf (Spanish) pdf

HIPAA Release of Informationpdf 

HIPAA Release of Information Revocation
pdf

 

Pharmacy Forms

WellCare Member Registration and Prescription Mail-Order pdf

Request for Medicare Prescription Drug Coverage Determination pdf

  • Providers and members should fax form to 1-866-388-1767


WellCare Injectable Infusionpdf

Request for Redetermination of Medicare Prescription Drug Denial (Appeal) pdf


S5967_NA016572_PDP_WEB_ENG CMS Approved 11102011

Last modified: 01/17/2012
 

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