Forms

CarePlus Claim Form Cover Sheet (PDF) – Use this form when you have paid a provider up front for services covered under the CarePlus program or for services the provider is not submitting on your behalf. Some examples are childbirth classes, doula services, hearing aids and service animals.

CarePlus OON Recommendation Form (PDF) – Use this form to Pre-Certify Covered Procedures or for a retrospective approval of a designated Emergency Covered Procedure through AT&T CarePlus, when the provider is out-of-network.

CarePlus Procedure Form (PDF) – Use this form to Pre-Certify Covered Procedures or for a retrospective approval of a designated Emergency Covered Procedure through AT&T CarePlus, when the provider is in-network.

CarePlus Childbirth Classes Request Form (PDF) – Use this form if you are planning on attending childbirth classes.

CarePlus Doula Request Form (PDF) – Use this form if you are planning on using Doula services.

CarePlus Service Animal Request Form (PDF) – Use this form if you are planning on using a Service Animal.

CarePlus Hearing Aid(s) Claim Form (PDF) – Use this form after you have completed your hearing exam and have purchased your hearing aid(s).

CarePlus-Wellthy Veterans Services (PDF) – Use this form to submit for reimbursement for services provided for veterans by Wellthy.