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Web wellcare by fidelis care medicare resource for member rights, including, how to file appeals, and how to. Web wellcare by fidelis care. If you don’t agree with a decision made by the health insurance marketplace®, you may be able to file an. Web the provider appeals form must be used if a claim has been processed and a remittance advice has been issued. Web personal care benefit physician's order form (outside of new york city) doh 4359 (2010) (pdf) personal care benefit physician's. Medication request form (pdf) request for coverage redetermination of prescription drug.