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Additional Forms

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)

Late Enrollment Penalty (LEP) Reconsideration (PDF)

PCP Change Request Form - English (PDF)

If you have questions please, contact Member Services.