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Medicare : Appointment Of Representative Form

Appointment of Representative Form

Download a PDF copy of the Appointment of Representative Form by clicking on your preferred language below.

Mail to address:
WellCare Health Plans
P.O. Box 31368
Tampa, FL 33631-3368

If you have any questions when completing this form, contact us.

English pdf Spanish pdf 

The following forms confirm/revoke a Member's permission that WellCare may discuss or disclose Protected Health Information (PHI) to a particular person who acts as the Member's Personal Representative.

HIPAA Release of Information Form pdf

HIPAA Release of Information Revocation Form pdf

Y0070_NA023899_WCM_WEB_ENG CMS Approved

Last modified: 12/02/2013

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