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Home > Members 2023 > Important Plan Resources > Forms

Forms

Members, use the forms on this page to request payment, appoint a representative, and more.

Pharmacy forms

  • Coverage determination request form PDF
  • Personal medication list PDF January 18, 2023
  • Mail-order prescription form PDF and brochure with directions PDF
  • Recommended To-Do List PDF January 18, 2023
  • Request for Redetermination of Medicare Prescription Drug Denial

Other forms

  • Appoint a representative PDF | Instructions
    Use this form to appoint a representative to act on your behalf regarding your appeal request.
  • Prior authorization form PDF
  • Personal Representative Request Form PDF
    This form will be used to confirm a member's permission that First Choice VIP Care Plus may discuss or PHI to a particular person who acts as the member's personal representative.
H8213_001_WEB_2099651
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This site contains links to other internet sites. First Choice VIP Care Plus is not responsible for the content of these sites. Please see Terms of Use, Privacy Notice, and Potential for Contract Termination.

First Choice VIP Care Plus is a health plan that contracts with both Medicare and South Carolina Healthy Connections Medicaid to provide benefits of both programs to enrollees. This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the First Choice VIP Care Plus Member Handbook (PDF).

You can get this information in a language other than English or in another format. Call 1-888-978-0862 (TTY 711), 8 a.m.- 8 p.m., 7 days a week. You can make a request to get this information, now and in the future, in a language other than English or in another format simply by calling Member Services at 1-888-978-0862 (TTY 711), 8 a.m. - 8 p.m., 7 days a week.

We'll also ask for your preference during our Welcome Call and later in the year, when you contact the plan. The plan will store your request and continue to send future documents in this requested language or format, unless you ask us to cancel or change the request. You can cancel or change your request at any time, simply by calling Member Services. The calls are free.

First Choice VIP Care Plus complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-978-0862 (TTY 711), de 8 a.m. a 8 p.m., los siete días de la semana. La llamada es gratuita.

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