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


Nebraska Home Health Prior Authorization Request Form

Nebraska Department of Health and Human Services Medicaid and Long-Term Care - HERITAGE HEALTH Prior Authorization for Hearing Aids

Save time! Submit and review your requests online @

Behavioral Health


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

Other Forms


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Last Updated On: 2/4/2019
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