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.
Medical claim reimbursement form — Complete this form with the help of your healthcare provider to get reimbursed for a medical claim.
Rewards reimbursement form - Use this form to have funds added to your OTC Rewards card for completing qualifying health exams.
Nonemergency medical transportation - Get reimbursed for transportation to medical appointments. Trips must be pre-approved.
Diaper reimbursement form - See your doctor or midwife between 1 to 12 weeks post-partum and we'll send you a box of diapers at no cost to you.
Prenatal visit form — Complete this form and have your doctor sign it to earn funds on your OTC Rewards card.
Fitness and WeightWatchers® reimbursement form — Complete this form to receive your GetFit! fitness club and WeightWatchers® reimbursement.
New Hampshire Medicaid formulary (list of covered drugs)
Mail order prescription program enrollment form — Order maintenance medications through our mail order pharmacy.
Prescription drug reimbursement form
Assign or revoke a personal representative form— Name someone you know and trust to communicate with our plan on your behalf.
- English
- Formulario para Designar un Representante Personal
- Haitian Creole
- Complete in the WellSense member portal
Care Management PHI authorization form — This document gives us permission to share your information with healthcare providers and community organizations, as needed, to manage your care.
Minor consent to travel alone form - This form grants permission for MTM to transport children under 16 years old to medical appointments with permission from a parent or guardian.
Notification of birth form - This form must be completed within 24 hours of birth.
Privacy practices — Learn how we keep your personal medical information confidential.
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.
Release of Reproductive Healthcare Attestation
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.
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