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.
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.
Y0070_NA023899_WCM_WEB_ENG CMS Approved
Last modified: 12/02/2013