Get *wellcarecom Form

Filling out the wellcarecom Form online is essential for requesting behavioral health services. This guide will help you navigate each section of the form, ensuring you provide all necessary information accurately.

Follow the steps to complete your request effectively.

1. Click ‘Get Form’ button to access the wellcarecom Form for behavioral health service requests.
2. Begin by filling out the member information section. Provide the member's last name, first name, middle initial, date of birth, phone number, WellCare ID number, and gender. If the member has third-party insurance, indicate 'Yes' or 'No' and attach a copy of the insurance card if available.
3. Next, provide details about the treating provider or practitioner. Include their last name, first name, WellCare ID number, street address, phone number, NPI number, specialty, and fax number.
4. Fill out the facility or agency information. Enter the name, street address, phone number, facility ID, NPI number, city, state, ZIP code, and office contact.
5. Indicate the type of service requested and list the relevant Rev/CPT/HCPS codes. Specify the requested number of units, ensuring it does not exceed a three-month period.
6. Provide the primary and secondary diagnosis and any medical problems relevant to the request.
7. Choose the treatment phase: initiation, continuation, or stabilization/maintenance. If court-ordered services are requested, attach the necessary documentation.
8. Describe risk factors and symptoms relevant to the member's behavioral health. Include their baseline behavior, details about any inpatient admissions, severity ratings in functional areas, and provide any relevant narratives explaining treatment interventions.
9. Outline discharge goals for each functional area of concern and include the discharge plan date. Indicate adherence to therapy and medications.
10. Lastly, review all provided information for accuracy. Users can save changes, download, print, or share the completed form once they have finished.

Complete your wellcarecom Form online today for your behavioral health service requests.