Commonly Requested Forms
Appointment of Representative Form* — (For use with organizational determinations, appeals and grievances ONLY)
LIS 2018 Premium Summary Chart (PDF)
Authorization to Release Personal Health Information to a Friend or Family Member (PDF)
Health Care Proxy (PDF)
Download the Senior Whole Health Enrollment Application (PDF)
Medicare Complaint Form*
Online Request for Medicare Part D Redetermination
Download the Request for Redetermination of Medicare Prescription Drug Denial (PDF)
Online Request for Medicare Part D Prescription Drug Coverage Determination
Request for Medicare Part D Prescription Drug Coverage Determination (PDF) in ENGLISH
Medicare Reconsideration Request Form (PDF)
Prior Authorization Forms
Drug Coverage Determination Form (PDF) in ENGLISH
Download the Senior Whole Health 2018 Prior Authorization Criteria (PDF).
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Last Updated 02/08/2018