Documents and forms
Medical
Medical claim reimbursement form — Complete this form with the help of your healthcare provider to get reimbursed for a medical claim.
OTC rewards card
Rewards reimbursement form - Use this form to have funds added to your OTC Rewards card for completing qualifying health exams.
Nonemergency medical transportation
Get reimbursed for transportation to medical appointments. Trips must be pre-approved.
- Family and friends mileage reimbursement form
- Friends and family mileage reimbursement – direct deposit form
Incentives
Diaper reimbursement form - See your doctor or midwife between 1 to 12 weeks post-partum and we'll send you a free box of diapers.
Prenatal Visit Form — Complete this form and have your doctor sign it to earn funds on your OTC Rewards card.Fitness
Fitness and WeightWatchers® reimbursement form — Complete this form to receive your GetFit! fitness club and WeightWatchers® reimbursement.New Hampshire Medicaid formulary (list of covered drugs)
Mail order prescription program enrollment form — Order maintenance medications through our mail order pharmacy.
Prescription drug reimbursement form
Advance directive form — This document includes a Durable Power of Attorney and a Living Will Disclosure Statement and Form, which gives the person you name as your health care agent the power to make any and all health care decisions for you when you lack the capacity to make those decisions for yourself.
Appeals representative authorization form — This document lets you give someone you know and trust permission to act on your behalf for an appeal.
Assign or revoke a personal representative form— Name someone you know and trust to communicate with our plan on your behalf.
Care Management PHI authorization form — This document gives us permission to share your information with healthcare providers and community organizations, as needed, to manage your care.
Minor consent to travel alone form - This form grants permission for CTS to transport children under 16 years old to medical appointments with permission from a parent or guardian.
Notification of birth form - This form must be completed within 24 hours of birth.
Privacy practices — Learn how we keep your personal medical information confidential.
Release of information form — This form is used to authorize WellSense to release your PHI to you or to another organization. WellSense Health Plan is a managed care organization (MCO), not a medical provider. Requests for medical records must be directed to your medical providers.
Release of Reproductive Healthcare Attestation
Request for access to information form — This form is used to request a copy of your member information from WellSense. Your information includes but is not limited to your medical claims, pharmacy claims, copays, case management, vision claims and behavioral health claims. The record does not include your medical records.
Request for confidential communication form — Make a request to receive communications with protected health information (PHI) by alternative means or at another location.
You are leaving the WellSense website
You are now leaving the WellSense website, and are being connected to a third party web site. Please note that WellSense is not responsible for the information, content or product(s) found on third party web sites.
By accessing the noted link you will be leaving our website and entering a website hosted by another party. Please be advised that you will no longer be subject to, or under the protection of, our privacy and security policies. We encourage you to read and evaluate the privacy and security policies of the site you are entering, which may be different than ours.