Commonly Requested Forms
Appointment of Representative Form* — (For use with organizational determinations, appeals and grievances ONLY)
LIS 2019 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 Medicare Advantage & Senior Care Options (SCO) Enrollment Application (PDF)
Download the Senior Whole Health Senior Care Options (SCO) 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 2019 Prior Authorization Criteria (PDF).
*By clicking on this link you will be leaving the Senior Whole Health website.
Click here to access Provider Forms.
Enroll in Medicare as a Provider Now! Learn more.
Visit the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) to securely and electronically submit and manage Medicare enrollment information.
Last Updated 1/08/2019