Wellcare By Allwell 2023 In-Network Provider Acknowledgment

Your practice is participating in our Medicare Advantage program, Wellcare By Allwell, effective January 1, 2023.

If you have questions about Wellcare By Allwell or other programs that are new to your practice, please contact:

Enrollment Attestation

Practice Name *

TIN *

Additional TINs Please list any additional TINs that should be represented on this form.

Practice Phone

Attester Name

Attester Title

Attester Email

Attester Phone Number

I acknowledge and understand that the above-named practice is part of the Wellcare By Allwell network. Acknowledged