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.
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