MEDICARE MEMBERS: PROTECT YOURSELF AGAINST MEDICARE FRAUD AND IDENTIFY THEFT! THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OFFICE OF INSPECTOR GENERAL IS ALERTING THE PUBLIC ABOUT A FRAUD SCHEME INVOLVING GENETIC TESTING. LEARN HOW TO PROTECT YOURSELF.
Additional Member Forms |
Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.
- PHI Authorization Form - English (PDF)
- PHI Authorization Form - Spanish (PDF)
- Use this form when you want to allow Allwell to share your health information with a person or group.
- PHI Revocation Form (PDF)
- Use this form when you want Allwell to cancel or revoke your previous permission to share health information with a person or group.