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  • Fidelis Care Medication Request Form

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FIDELIS CARE MEDICATION REQUEST FORM(8/2018)Medicaid, Child Health Plus, and Qualified Health PlansComplete form and fax to 18775332405. For Medicaid, Child Health Plus, and Qualified Health Plans.

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Wellcare Fidelis No Premium (HMO) and Wellcare Fidelis Patriot No Premium (HMO-POS) have a network of doctors, hospitals, pharmacies, and other providers.

Fidelis Care offers free online claims submission through Ability's claims portal. To learn more about Ability, call 1-888-499-5465 or visit .mdon-line.com/fideliscare. You also have the option to contact another clearinghouse to initiate 837-claim submission to Fidelis Care.

Must be submitted via the appropriate fax line or by phone at 1-888-FIDELIS (1-888-343-3547): Urgent Requests.

Requests for administrative review must be sent to the following address: Attn: Claims Reconsideration, Fidelis Care, 480 CrossPoint Parkway, Getzville, NY 14068.

Fidelis Care, a leading health insurer that serves all of New York State, offers free or low-cost comprehensive health coverage, including Medicaid Managed Care, Medicare Advantage, Child Health Plus, and plans available through NY State of Health, The Official Health Plan Marketplace.

IMPORTANT – Claims must be submitted within 90 (ninety) days from the date of service.

Payer ID: 11315 Note: Customer Service: (888) 343-3547.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232