Documents and Forms
Health Risk Assessment — Complete your health risk assessment so we can help provide better health services and coordinate the care you receive. You can also call Member Services to take the assessment. View the form in Spanish.
Advance Directive Form — This document includes a Durable Power of Attorney and a Living Will Disclosure Statement and Form, which gives the person you name as your health care agent the power to make any and all health care decisions for you when you lack the capacity to make those decisions for yourself.
Authorized Representative Form — This document lets you give someone you know and trust permission to act on your behalf for an appeal. View the form in Spanish.
Care Management PHI Authorization Form — This documents gives us permission to share your information with healthcare providers and community organizations, as needed, to manage your care. View the form in Spanish.
Fitness Reimbursement Form — Print, complete and send back this form to receive your GetFit! reimbursement.
Mail Order Prescription Enrollment Form — Order maintenance medications through our mail order pharmacy.
Medical Claim Reimbursement Form — Complete this form with the help of your healthcare provider to get reimbursed for a medical claim.
Personal Representative Designation Request Form — This document lets you name someone you know and trust to make healthcare decisions for you if, for any reason, you become unable to make decisions or communicate your wishes to doctors. View the form in Spanish.
Pregnancy Notification Form — Complete this form and have your doctor sign it to earn funds on your OTC Rewards cards. The completed form must be returned to us within 30 days of your first visit to the doctor.
Prenatal Visit Form — Complete this form and have your doctor sign it to earn funds on your OTC Rewards cards.
Prescription Reimbursement Form — Request reimbursement for any covered prescriptions that you paid for out of pocket.
Privacy Practices — Learn how we keep your personal medical information confidential.
Request for Access to Information Form — This form is used to request a copy of your member information from WellSense. Your information includes but is not limited to your medical claims, pharmacy claims, copays, case management, vision claims and behavioral health claims. The record does not include your medical records.
Request for Confidential Communication Form — Make a request to receive communications with protected health information (PHI) by alternative means or at another location.
Request for Release of Information Form — This form is used to authorize WellSense to release your PHI to you or to another organization. WellSense Health Plan is a managed care organization (MCO), not a medical provider. Requests for medical records must be directed to your medical providers.
Request for Revocation of Release of Information Form — This document lets you remove a previously authorized person or organization from receiving your PHI.
Revocation of Personal Representative Form — This document lets you remove a previously assigned representative from making important healthcare decisions for you.
Transportation Reimbursement Request Form — Get reimbursed for transportation to medical appointments. Trips must be pre-approved. For trips prior to July 1, 2022, please use this form.
WW® Wellness Incentive Form — Print, complete and send this form back to WW® (formerly Weight Watchers®) to receive your WW® reimbursement.