Forms

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

Pharmacy forms

• Coverage determination request form (PDF) Opens a new window
• Personal medication list (PDF) Opens a new window
• Mail-order prescription form (PDF) Opens a new window and brochure with directions (PDF) Opens a new window
• Recommended To-Do List (PDF) Opens a new window
• Request for Redetermination of Medicare Prescription Drug Denial

Other forms

• Appoint a Representative (PDF) Opens a new window | Instructions
  Use this form to appoint a representative to act on your behalf regarding your appeal request.
• Health Care Privacy Complaint Form (PDF) Opens a new window
• Prior Authorization Form (PDF) Opens a new window
• Personal Representative Request Form (PDF) Opens a new window
• Request for Alternate Means of Confidential Communications (PDF) Opens a new window.
• Request to Amend Protected Health Information (PDF) Opens a new window
• Request for List of Disclosures of Protected Health Information (PDF) Opens a new window
• Request to Restrict the Use and/or Disclosure of Protected Health Information (PDF) Opens a new window
• Revocation of Alternate Means of Confidential Communications (PDF) Opens a new window

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