- Advanced Beneficiary Notice (ABN) (PDF)
- All States Provider Address Form (PDF)
- Billing-Mailing Address Change Form (PDF)
- Claim Appeal / Reconsideration Request Form (PDF)
- Closing an Office Form (PDF)
- Fax Cover Sheet for Claim Attachments (PDF)
- Non-Covered Services Liability Acknowledgement (PDF)
- Ownership and Control Disclosures Form (PDF)
- Panel Participation Request Form (PDF)
- Provider Termination from Panel Request Form (PDF)
- Replacement Eyewear Acknowledgement (PDF)
- Statement of Controlled Substance Coverage (PDF)
Effective June 1, 2026: Ophthalmologists must have a DEA license and/or CDS certificate (as applicable). If not available, download and submit the above waiver form (Statement of Controlled Substance Coverage) or a written prescribing protocol. Credentialing cannot proceed without one of these on file. - Vision Care Eyeglasses Patient Certification Form (PDF)
- Waiver of Liability Form (PDF)
An Appointment of Representative form (AOR) allows a Medicare member to name someone they trust—such as a family member, caregiver, or provider—to speak with Wellcare and help with matters like claims, appeals, or coverage questions. The member keeps full control and can change or cancel the AOR at any time.
- Closing an Office Form (PDF)
- Disclosure of Ownership and Control Interest Statement (PDF)
- Electronic Claims Submission through Inmediata (PDF)
- EVB Puerto Rico Prior Notification Form (PDF)
- Non-Covered Service Liability Acknowledgment Form (PDF)
- Provider Address Form (PDF)
- Puerto Rico Billing-Mailing Address Change Form (PDF)
- Puerto Rico Provider Termination from Panel Request Form (PDF)
- Statement of Controlled Substance Coverage Form (PDF)
- Non-Contracted Provider Payment Dispute Process (PDF)
Submission of credentialing materials does not guarantee the processing or approval of your participation with us. All submitted materials will be reviewed and responded to accordingly.
For your protection, our privacy policy prevents us from responding to emails containing protected health information (specific information about you and your healthcare) because we cannot guarantee the security of these e-mails before they reach us. Please contact your customer service representative should you have questions or concerns regarding your eye care services.