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This form can be used to record mileage for member reimbursement.


Refund Check Information Sheet* (RCIS)


Nebraska Medicaid and Long-Term Care Informed Consent Form for Treatment of Opioid Use Disorder To be completed upon initiation of therapy with Buprenorphine/Naloxone or Buprenorphine

Drug Prior Authorization Requests Supplied by the Physician/Facility

Please complete and submit this form to request coverage through the WellCare of Nebraska Medicaid plan.

Nebraska Tobacco Quitline

Other Forms

Chlamydia is the most common sexually transmitted bacterial infection (STI) in the United States. The best way to detect chlamydia in its early stages is to conduct screenings at yearly physicals for patients who are sexually active.

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Naudi a Napabaro Idi: 12/4/2020
Medicare Members: Your materials are on the way! We realize you may be waiting to receive some plan materials and we apologize for any delays. Did you know you can go online to our member portal to view Member materials, review your benefits, request or download an ID card, or choose a physician (when applicable)? Log in or register today!