• Transition of Care Form - English (PDF)
• Transition of Care Form - Spanish (PDF)

• PHI Authorization Form - English (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.

Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

• Appointing a Representative (PDF)

• Member Reimbursement Claim Form - English (PDF)
• Member Reimbursement Claim Form - Spanish (PDF)

• Late Enrollment Penalty (LEP) Reconsideration (PDF)

• 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.

• Member Reimbursement Claim Form - English (PDF)
• Member Reimbursement Claim Form - Spanish (PDF)

• Late Enrollment Penalty (LEP) Reconsideration (PDF)