Back to wellchoice.com Home
Home > Find a Form or Brochure

Otherwise, please choose from one of the following categories:
- Small Groups: 2-50 employees.
- Large Groups: Over 51 employees.
- Brokers: Forms and brochures you need to sell our plans and become a WellChoice Broker.
- Other Forms and Brochures
- WellChoice:The HMO for employees who reside in New York.
You need Adobe Acrobat to view PDF files. Get Adobe Acrobat.
Small Groups
General Forms (All Plans)
- Small Group HMO/Accesssm HMO Benefits Summary
A detailed benefit summary of WellChoice HMO and Wellchoice Accesssm HMO.
- Small Group PPO Benefits Summary 100/70
A detailed benefit summary of our WellChoice PPO.
- Small Group PPO Benefits Summary 90/70
A detailed benefit summary of our WellChoice PPO.
- Small Employer Health Benefits Application
For employer application to our Small Group HMO, Accesssm HMO or PPO plans.
- Small Group Employee Application/Change Form
For enrollment of employees and their dependents in our Small Group HMO, Accesssm HMO or PPO plans.
- Certification Form
To determine that your company meets yearly guidelines required by the State of New Jersey.
- Pre-Existing Condition Statement
To notify us of a pre-existing medical condition. (For groups 2-5 in size as required by the State Of New Jersey.)
- Student Coverage Questionnaire
To determine if a dependent is a valid student and still eligible for coverage.
- Waiver of Coverage Form
To waive WellChoice coverage.
- Re-Certification Form
To determine that your company still meet the yearly guidelines required by the State of New Jersey on renewals.
- Pharmacy Mail Order Form
To receive prescriptions by mail.
 BACK TO TOP
WellChoice PPO
- Medical Claim Form
To submit an out-of-network medical claim.
- Prescription Claim Form
To receive reimbursement for prescriptions paid for out-of-pocket.
 BACK TO TOP
Large Groups
General Forms (All Plans)
- Large Group HMO/Accesssm HMO Benefits Summary
A detailed benefit summary of WellChoice HMO and Wellchoice Accesssm HMO.
- Large Group PPO Benefits Summary 100/70
A detailed benefit summary of our WellChoice PPO.
- Large Group Benefit Application
For employer application to our Large Group HMO or PPO plans.
- Large Group HMO Benefit Application
For employer application to our Large Group HMO plans.
- Large Group Employee Application/Change Form
For enrollment of employees and their dependents in our Large Group HMO, Accesssm HMO or PPO plans.
- Student Coverage Questionnaire
To determine if a dependent is a valid student and still eligible for coverage.
- Waiver of Coverage Form
To waive WellChoice coverage.
- Pharmacy Mail Order Form
To receive prescriptions by mail.
 BACK TO TOP
WellChoice PPO
- Medical Claim Form
To submit an out-of-network medical claim.
- Prescription Claim Form
To receive reimbursement for prescriptions paid for out-of-pocket.
 BACK TO TOP
Brokers
- Broker of Record Letter
- Agent/Broker Information
General information about becoming a WellChoice broker.
- Brokerage Agreement
- Business Associate Agreement
To establish a relationship with WellChoice as a selling agent
- Solutions Brochure
A description of WellChoice healthplans and programs.
Other Forms and Brochures
- Individual Authorization Form
Complete this form for release of PHI and clinical information from Provider to Company. If member wishes to disclose clinical information and psychotherapy notes, member must complete both the Individual Authorization Form and Psychotherapy Notes Authorization Form.
- Psychotherapy Notes Authorization Form
Complete this form for release of psychotherapy notes from Provider to Company. If member wishes to disclose clinical information and psychotherapy notes, member must complete both the Individual Authorization Form and Psychotherapy Notes Authorization Form.
- WellChoice Referral Form
- Health Care Provider Application to Appeal a Claims Determination
- General Fax Authorization Request
This form is used by physicians only to request the authorization of certain services.
- Release of Information Form
Authorization to release information and/or designation of a representative.
- Provider Nomination Card
To nominate a provider who is not listed in our directory.
- Handicapped/Dependent Form (HAC 506)
To receive coverage for an unmarried dependent child over the contract age limit who is developmentally disabled, mentally ill or physically handicapped.
- Medical Support Orders
Administration of Qualified Medical Child Support Order (QMCSO) or National Medical Support Notice (NMSN)
- Release of Clinical Information Consent Form
Authorizes the use and disclosure of psychotherapy notes as required by federal law
 BACK TO TOP












Contact Us    Site Index
Fraud & Abuse    Privacy Notices    Legal Notice
Services and products provided by WellChoice Insurance of New Jersey, Inc. and WellChoice HMO of New Jersey.

© Copyright 2004 WellChoice Insurance of New Jersey, Inc. All rights reserved.