This form can be used to record mileage for member reimbursement.
Drug Prior Authorization Requests Supplied by the Physician/Facility
Nebraska Department of Health and Human Services Medicaid and Long-Term Care - HERITAGE HEALTH Prior Authorization for Hearing Aids
Nebraska Home Health Prior Authorization Request Form
Save time! Submit and review your requests online @ https://provider.wellcare.com
Refund Check Information Sheet* (RCIS)
Nebraska Medicaid and Long-Term Care Informed Consent Form for Treatment of Opioid Use Disorder To be completed upon initiation of therapy with Buprenorphine/Naloxone or Buprenorphine
Please complete and submit this form to request coverage through the WellCare of Nebraska Medicaid plan.
Nebraska Tobacco Quitline
