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