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Forms

Administrative

This form can be used to record mileage for member reimbursement.

Authorizations

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

Behavioral Health

Claims

Refund Check Information Sheet* (RCIS)

Pharmacy

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

Drug Prior Authorization Requests Supplied by the Physician/Facility

Please complete and submit this form to request coverage through the WellCare of Nebraska Medicaid plan.

Nebraska Tobacco Quitline

Other Forms

Chlamydia is the most common sexually transmitted bacterial infection (STI) in the United States. The best way to detect chlamydia in its early stages is to conduct screenings at yearly physicals for patients who are sexually active.

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Last Updated On: 10/22/2020