Documents and forms
You can find and complete many forms on the WellSense member portal.
If you'd rather download and print a paper copy, find your form from the list below.
- Prescription Drug Reimbursement Form
- Mail Order Prescription Form
| Title | Language |
|---|---|
|
Care Needs Screening You can also complete your Care Needs Screening online. |
English |
| Allow Care Management to Obtain Protected Health Information Formulario de Autorización de PHI para Programa de Manejo de Cuidado Fòmilè Otorizasyon Jesyon Swen ESP Formulário de autorização de PHI para gestão de atendimentos Quản lý Dịch vụ Chăm sóc Mẫu đơn Ủy quyền PHI 照護管理 PHI 授權表 |
|
| Assign an Appeals Representative Formulario de autorización de representante para apelación |
|
| Assign and Revoke a Personal Representative Formulario para Designar un Representante Personal Formulário de Indicação de Representante Pessoal Fòm pou Deziyen yon Reprezantan Pèsonèl |
|
| Release of Reproductive Healthcare Attestation | English |
| Request for Access to Information | English Spanish |
| Request to Release Information Formulario de divulgación de información Formulário de Divulgação de Informações Fòm pou Pibliye Enfòmasyon |
English Spanish Portuguese Haitian Creole |
IMPORTANT 2025 TAX INFORMATION
WellSense Clarity plan members' 2025 1095-A and 1095-B tax forms will be ready to view and download through our Member Portal.
1095-A and 1095-B Tax Forms – Q & A
This year you will receive two forms that you will need to complete your taxes. Below you will find relevant information about these forms.
Who receives the 1095-A form?
New Hampshire residents age 18 and over who were enrolled in a WellSense Clarity plan through Healthcare.gov.
Who sends out the 1095-A form?
Healthcare.gov sends out the 1095-A form. Please call Healthcare.gov at 800-318-2596 for any questions, including duplicate requests, about this form.
Who receives the 1095-B form?
New Hampshire residents age 18 and over who were enrolled in an off-exchange WellSense Clarity plan at any point in 2025.
Who sends out the 1095-B form?
WellSense sends the 1095-B form to off-exchange WellSense Clarity plan members.
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