• PHI Authorization Forms  - Use this form when you want to allow Allwell to share your health information with a person or group.
  • Authorization to Disclose Health Information Form (Electronic)
  • Formulario de autorización para divulgar información de salud (Electrónico)

• PHI Revocation Forms - 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)

Material ID: Y0020_SHP_20228996_C Internally Approved 06/29/2022

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 Forms  - Use this form when you want to allow Allwell to share your health information with a person or group.
  • Authorization to Disclose Health Information Form (Electronic)
  • Formulario de autorización para divulgar información de salud (Electrónico)

• PHI Revocation Forms - 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)

• PCP Change Request Form - English (PDF)
• PCP Change Request Form - Spanish (PDF)

• Late Enrollment Penalty (LEP) Reconsideration (PDF)