Baird Appeals Form

  • Request for Waiver - Appeal Form Secure Submission

    Submit your completed Request for Waiver - Appeal Form by 5 PM CT on September 19, 2025.

    Your form will be added to your B\Well account within 10 business days. If additional information is needed, you will be notified by email. If your form is approved, you will be notified by email.

    Before you submit your form, please complete the following steps:

    • Print clearly and review your form to ensure it is complete
    • Provide a valid email address so we can contact you regarding the status of your form
    • Ensure you and your doctor has signed your form - Both signatures are required
    • Ensure that all applicable boxes are checked

    Contact WebMD Customer Service at 888-343-9861 with questions.







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