• Transition of Care Form (PDF)

• Use this form when you want to allow Allwell to share your health information with a person or group.
  • PHI Authorization Form - English (PDF)

• Use this form when you want Allwell to cancel or revoke your previous permission to share health information with a person or group.
  • PHI Revocation Form - English (PDF)
  • PHI Revocation Form - Spanish (PDF)

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)

We have free interpreters to answer questions in multiple languages. Call Member Services.

• Multi-language Interpreter Services Form (PDF)

• Office Visit Checklist (PDF)

• Late Enrollment Penalty (LEP) Reconsideration (PDF)

• Transition of Care Form (PDF)

• Use this form when you want to allow Allwell to share your health information with a person or group.
  • PHI Authorization Form - English (PDF)
  • PHI Authorization Form - Spanish (PDF)

• Use this form when you want Allwell to cancel or revoke your previous permission to share health information with a person or group.
  • PHI Revocation Form - English (PDF)
  • PHI Revocation Form - Spanish (PDF)

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

• Office Visit Checklist (PDF)

We have free interpreters to answer questions in multiple languages. Call Member Services.

• Multi-language Interpreter Services Form (PDF)

• Late Enrollment Penalty (LEP) Reconsideration (PDF)