Additional Member Forms | Wellcare Nebraska

Additional Forms

 

  • Transition of Care Form - English (PDF) - coming soon
  • Transition of Care Form - Spanish (PDF) - coming soon

Use this form when you want to allow us to share your health information with a person or group:

  • PHI Authorization Form (PDF) - coming soon

Use this form when you want us to cancel or revoke your previous permission to share health information with a person or group:

  • PHI Revocation Form (PDF) - coming soon

 

Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

If you have questions please, contact Member Services.